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 {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
- Urine pH 5.0: This is an improvement as the pH has increased from 4.4, moving closer to the normal range (4.6 to 8).
- Urine specific gravity 1.050: This is a sign of potential worsening as the specific gravity has increased from 1.040, indicating possible dehydration.
- 3+ ketones: This is a sign of potential worsening as the presence of ketones has increased from 2+, indicating the body is breaking down fat for energy due to insufficient glucose.
- Urinary output 40 mL/hr: This is an improvement as the urinary output has increased from 20 mL/hr, indicating better hydration.
- Heart rate 130/min: This is a sign of potential worsening as the heart rate has increased from 128/min, possibly due to dehydration.
- WBC count 10,000/mmt: This is unrelated to the diagnosis as it’s within the normal range (5,000 to 10,000/mm³) and doesn’t directly relate to the client’s symptoms of vomiting and dehydration.
Correct Answer is A
Explanation
Choice A rationale
Assessing for edema is an important action for the nurse to take when caring for a client who is 1 hr postpartum and has preeclampsia without severe features. Edema can be a sign of worsening preeclampsia.
Choice B rationale
Administering an IV bolus of lactated Ringer’s is not typically necessary for a client with preeclampsia without severe features.
Choice C rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to induce labor or treat postpartum hemorrhage, not preeclampsia.
Choice D rationale
Assisting the client with food intake is not directly related to the management of preeclampsia
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