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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A Coombs positive result does not necessarily mean that the newborn will require immediate intervention. It indicates that the newborn should be monitored for potential complications such as jaundice and anemia.
Choice B rationale
While the newborn’s glucose level is within the normal range, this does not directly relate to the Coombs positive result.
Choice C rationale
A Coombs positive result may indicate Rh or ABO incompatibility, but this does not directly answer the question of what the nurse should anticipate.
Choice D rationale
This is the correct answer. A Coombs positive result indicates that the newborn should be monitored for signs of jaundice, as this could be a potential complication.
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.
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