A nurse is caring for a 28-year-old female client in the postpartum unit who gave birth 3 days ago. The client had a cesarean birth following prolonged rupture of membranes and cephalopelvic disproportion. The client reports general malaise, chills, and a decreased appetite.
The Correct Answer is []
• Endometritis: The client’s symptoms such as general malaise, chills, decreased appetite, elevated temperature, boggy and tender uterus, and foul-smelling lochia suggest that she is most likely experiencing endometritis, an inflammation of the inner lining of the uterus, typically due to infection.
• Actions to take: The nurse should administer the prescribed IV antibiotics to treat the infection. The nurse should also encourage fluid intake to help flush out the bacteria from the body and prevent dehydration.
• Parameters to monitor: The nurse should monitor the client’s temperature to assess for fever, which can be a sign of infection. The nurse should also monitor the amount and odor of the client’s lochia, as changes can indicate worsening infection. If the client’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While blood in the stool can be a sign of a problem in older children and adults, it is not uncommon for newborns to pass dark green or black stools (known as meconium) in the first few days after birth. This does not typically indicate a problem.
Choice B rationale
A newborn vomiting eight to ten times per day is a cause for concern. This could indicate a problem such as pyloric stenosis or gastroesophageal reflux disease, both of which require medical attention.
Choice C rationale
Cooling after each breastfeeding is not typically a sign of a problem. Newborns have immature temperature regulation systems, so slight variations in body temperature can occur.
Choice D rationale
Persistent crossing of the eyes in a newborn can be normal up to about 3 months of age. If it continues beyond this point, it may indicate a problem such as strabismus.
Correct Answer is D
Explanation
Choice A rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The goal of phototherapy is to expose the newborn’s skin to light, and applying lotion could potentially interfere with the effectiveness of the treatment.
Choice B rationale
Providing the newborn with 15 mL glucose water after each feeding is not a standard part of phototherapy treatment. The newborn should continue to receive regular feedings, but additional glucose water is not typically necessary.
Choice C rationale
Turning the newborn every 4 hours is not sufficient during phototherapy. The newborn should be repositioned frequently, ideally every 2-3 hours, to expose all areas of the skin to the light.
Choice D rationale
It is important to protect the newborn’s eyes during phototherapy to prevent damage from the light. Therefore, the newborn’s eyes should be covered with special patches whenever the lights are on.
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