A nurse is assisting with the care of a client who gave birth 3 days ago.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Blurred vision can indicate a prenatal complication, such as preeclampsia, which is a serious condition that can develop in the later stages of pregnancy and requires immediate attention. Preeclampsia can lead to severe health issues for both the mother and baby.
B. Shortness of breath can be a normal part of late pregnancy due to the pressure on the diaphragm from the growing uterus. While it should be monitored, it is not specifically indicative of a complication compared to other symptoms.
C. Non-pitting ankle edema is common in the later stages of pregnancy and is not necessarily a sign of a complication on its own. It can occur due to the increased fluid volume and pressure from the uterus.
D. Leukorrhea, or increased vaginal discharge, is a common and normal finding in pregnancy, especially as labor approaches. It is generally not a sign of a complication unless accompanied by other concerning symptoms.
Correct Answer is B
Explanation
A. Placing a rolled blanket behind the newborn’s neck is unsafe and can cause improper positioning in the car seat. The newborn should be positioned properly according to the car seat manufacturer's instructions to ensure safety during travel.
B. The car seat should be positioned at a 45° angle to keep the newborn’s airway open and prevent slumping. This angle supports proper head and neck alignment, which is essential for the baby’s safety and comfort during travel.
C. The retainer clip should be positioned at the level of the newborn’s armpits, not the umbilicus. Proper placement of the retainer clip ensures that the harness is secure and correctly positioned over the baby’s shoulders.
D. Newborns should be placed in a rear-facing position in the car seat for optimal safety. Forward-facing car seats are used later, but infants should always be in a rear-facing car seat until they meet the age, weight, and height requirements for transitioning.
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