A nurse is assisting with the care of a postpartum 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 evaluate the client's progress.
The Correct Answer is []
- Endometritis. The client has fever (38.4°C/101.1°F), tachycardia (HR 108/min), uterine tenderness, and foul-smelling lochia, all of which indicate postpartum uterine infection. Prolonged rupture of membranes and cesarean birth increase the risk of endometritis.
- Engorgement. The client reports firm and heavy breasts but denies nipple discomfort, making engorgement unlikely as the primary issue.
- Deep vein thrombosis. The client has bilateral lower extremity edema but no pain, warmth, or tenderness, which are key signs of DVT.
- Urinary tract infection. The client reports frequent voiding without difficulty, with no dysuria or suprapubic pain, making a UTI unlikely.
- Plan to administer broad-spectrum antibiotic medication. Endometritis is a bacterial infection requiring IV broad-spectrum antibiotics, such as clindamycin and gentamicin, to prevent further complications.
- Administer an oxytocic medication. Oxytocic agents like oxytocin or methylergonovine help contract the uterus, promoting lochia drainage and reducing bacterial growth, which helps resolve infection.
- Apply ice packs to the breasts. This is used to relieve breast engorgement, but the primary concern is infection, not breast discomfort.
- Encourage the client to increase fluid intake. Hydration is important but does not directly treat endometritis, making it a lower priority.
- Initiate anticoagulant therapy. This is necessary for DVT management, but the client does not have symptoms of a clotting disorder.
- Temperature. Fever is a key sign of infection, and monitoring temperature helps assess the effectiveness of antibiotic therapy.
- Lochia amount and odor. Foul-smelling lochia is a major sign of endometritis, and monitoring for changes in amount or color helps evaluate treatment progress.
- Bladder distension. The client is voiding frequently without difficulty, making bladder monitoring unnecessary.
- Integrity of the nipples. This is only relevant for breastfeeding clients, and the client is bottle-feeding, making it not applicable.
- Circumference of lower extremities. This is monitored for DVT progression, which is not suspected in this client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide additional hydration by offering glucose water. Glucose water is not recommended for hydration or bilirubin elimination. Breast milk or formula should be the primary source of nutrition, as frequent feeding promotes stooling, which helps remove bilirubin from the body. Supplementing with glucose water can interfere with proper nutrition and milk intake.
B. Apply a water-based lotion to the newborn's skin every 4 hr. Lotion should not be applied to the newborn’s skin during phototherapy, as it can increase the risk of burns due to heat absorption from the phototherapy lights. Instead, keeping the skin clean and dry is essential to prevent irritation.
C. Monitor the newborn's heart rate every 2 hr. While vital signs should be monitored regularly, phototherapy primarily affects skin exposure, hydration, and bilirubin levels rather than cardiac function. The priority during phototherapy is monitoring temperature, hydration status, and bilirubin levels rather than frequent heart rate assessments.
D. Remove the newborn from phototherapy every 2 hr for breastfeeding. Frequent breastfeeding helps enhance bilirubin excretion through stooling and supports hydration. Short breaks from phototherapy for feeding are recommended to ensure adequate nutrition while maintaining effective bilirubin reduction. The newborn should be placed back under the lights as soon as feeding is completed.
Correct Answer is C
Explanation
A. "Position the lap belt across your navel." The lap belt should be positioned low across the hips and below the belly, not across the navel. Placing the belt too high increases the risk of abdominal trauma in the event of an accident, potentially harming the fetus.
B. "Wear the shoulder harness snug across your stomach." The shoulder harness should be positioned across the chest and over the shoulder, not across the stomach. Proper placement prevents excessive pressure on the abdomen and provides the best protection for both the mother and the baby in case of sudden stops or collisions.
C. "Take a break and walk at least once every hour during long trips." Pregnant clients are at increased risk of deep vein thrombosis (DVT) due to changes in circulation and increased blood volume. Walking every hour during long trips helps improve circulation, reduce swelling, and lower the risk of blood clots. Staying hydrated and performing ankle exercises while seated can also help prevent complications.
D. "Move your car seat forward, close to the steering wheel." The car seat should be positioned as far back as possible while still allowing the client to reach the pedals comfortably. Sitting too close to the steering wheel increases the risk of injury from the airbag in the event of a crash. Keeping at least 10 inches between the chest and the steering wheel provides better protection.
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