A nurse is caring for a client who had a cesarean delivery 24 hours ago.
The nurse notices that the client has a fever of 38.2°C, increased redness and swelling at the incision site, and foul-smelling lochia.
What is the most likely cause of these findings?
Infection
Hemorrhage
Deep vein thrombosis
Wound dehiscence.
The Correct Answer is A
The correct answer is choice A. Infection. The client’s fever, increased redness and swelling at the incision site, and foul-smelling lochia are all signs of infection, which is a common complication of cesarean delivery.
Choice B. Hemorrhage is wrong because hemorrhage would cause excessive bleeding, low blood pressure, and rapid pulse, which are not mentioned in the question.
Choice C. Deep vein thrombosis is wrong because deep vein thrombosis would cause pain, swelling, and tenderness in the legs, which are not mentioned in the question.
Choice D. Wound dehiscence is wrong because wound dehiscence would cause separation of the incision edges, drainage of serous fluid, and exposure of underlying tissues, which are not mentioned in the question.
Normal ranges for lochia are as follows:
• Lochia rubra: bright red blood and clots that last for 3 to 4 days after delivery
• Lochia serosa: pinkish-brown discharge that lasts for 4 to 10 days after delivery
• Lochia alba: yellowish-white discharge that lasts for 10 to 14 days after delivery
Foul-smelling lochia indicates infection and should be reported to the health care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Apply pressure to the bleeding site.This is because the client is showing signs of postpartum hemorrhage (PPH), which is severe vaginal bleeding after childbirth.PPH can occur up to 12 weeks postpartum, but it is more common within the first 24 hours.PPH can be caused by uterine atony, retained placenta, or trauma to the reproductive organs.
Applying pressure to the bleeding site can help to control the blood loss and prevent shock.
Choice B. Encourage early ambulation is wrong because it can worsen the bleeding and increase the risk of fainting.Early ambulation is beneficial for preventing thromboembolism and promoting recovery, but it should be done after the bleeding is stabilized.
Choice C. Apply sterile dressings to the incision is wrong because it does not address the source of bleeding, which is likely from the vagina or uterus.The incision site may also bleed, but it is usually less than the vaginal bleeding.
Applying sterile dressings to the incision can help to prevent infection, but it is not a priority intervention for PPH.
Choice D. Encourage frequent voiding is wrong because it can cause bladder distension and interfere with uterine contraction.A full bladder can displace the uterus and prevent it from compressing the blood vessels where the placenta was attached.
Encouraging frequent voiding can help to maintain bladder function and reduce discomfort, but it is not a priority intervention for PPH.
Normal ranges for heart rate are 60-100 beats per minute and for blood pressure are 90/60-120/80 mmHg.Normal blood loss after cesarean delivery is less than 1000 mL.
Correct Answer is B
Explanation
The correct answer is choice B. Cover the wound with a sterile, moist dressing and notify the healthcare provider.
This is because the client has a wound dehiscence with evisceration, which is a serious complication that requires immediate medical attention.
The sterile, moist dressing will help prevent infection and keep the bowel tissue moist until surgery can be performed.
Choice A is wrong because pushing the bowel back into the abdomen can cause further damage and increase the risk of infection and peritonitis.
Choice C is wrong because irrigating the wound with normal saline and applying an antibiotic ointment can also introduce bacteria and irritate the bowel tissue.
Choice D is wrong because leaving the wound exposed to air can cause the bowel tissue to dry out and necrose, which can lead to sepsis and shock.
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