A nurse is caring for a 28-year-old female client who gave birth 3 days ago via cesarean section following prolonged rupture of membranes and cephalopelvic disproportion. The client is currently in the postpartum unit.
A nurse is caring for 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 assess the client’s progress.
The Correct Answer is []
- Endometritis: The client’s symptoms such as general malaise, chills, decreased appetite, elevated white blood cell count, fever, a 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 antibiotics to treat the infection. The nurse should also educate the client on proper perineal hygiene to prevent further infection.
- 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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While magnesium sulfate can have an effect on the fetal heart rate, it does not primarily function to stabilize it. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties.
Choice B rationale
Magnesium sulfate does not primarily function to improve tissue perfusion. Its main role in the management of preeclampsia is to prevent seizures.
Choice C rationale
This is the correct answer. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties. It helps to prevent seizures in those with severe preeclampsia, which can minimize the risk of complications.
Choice D rationale
Magnesium sulfate does not increase cardiac output. Its primary role in the management of preeclampsia is to prevent seizures.
Correct Answer is C
Explanation
Choice A rationale
While applying a spermicidal cream or jelly to the diaphragm is recommended to increase its effectiveness, the use of a vaginal lubricant is not typically recommended.
Choice B rationale
Washing the diaphragm with mild soap and warm water is recommended after each use. However, using detergent soap may cause irritation and is not typically recommended.
Choice C rationale
The diaphragm can be inserted up to 6 hours before intercourse. This allows for flexibility and spontaneity.
Choice D rationale
The diaphragm should be left in place for at least 6 hours after intercourse, not 2 to 4 hours. This is to ensure that all sperm are killed by the spermicide.
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