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 A
Explanation
Choice A rationale
Puncturing the lateral side of the heel is the correct procedure when performing a heel stick on a newborn. This area is less likely to come into contact with hard surfaces that could cause injury to the puncture site.
Choice B rationale
A 21-gauge needle is too large for a heel stick procedure on a newborn. A smaller gauge needle or a lancet is typically used to ensure the puncture is as small and painless as possible.
Choice C rationale
Applying an alcohol pad to the site after the procedure is not recommended. Alcohol can cause skin irritation and dryness. Instead, a sterile gauze or bandage is usually applied to stop any bleeding from the puncture site.
Choice D rationale
Placing a cold cloth at the site for 15 minutes before the procedure is not recommended. Cold can cause vasoconstriction, which would make it more difficult to obtain a blood sample.
Instead, warming the heel prior to the stick can help to increase blood flow to the area.
Correct Answer is C
Explanation
Choice A rationale
Intramuscular injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice B rationale
Subcutaneous injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice C rationale
Intramuscular injection in the left vastus lateralis is the preferred route for administering phytonadione to a newborn. This muscle in the thigh is large enough to absorb the medication effectively.
Choice D rationale
Subcutaneous injection in the left vastus lateralis is not the preferred route for administering phytonadione to a newborn.
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