A nurse is caring for a female client who gave birth 3 days ago in the postpartum unit.
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 []
Rationale for correct condition Endometritis is a postpartum uterine infection, common after cesarean birth and prolonged rupture of membranes. The client presents with fever >38°C, uterine tenderness, and foul-smelling lochia, hallmark signs of endometritis. A boggy uterus indicates subinvolution due to infection. Malaise and chills reflect systemic inflammatory response. Bottle-feeding excludes mastitis or engorgement as primary cause.
Rationale for correct actions Broad-spectrum antibiotics like clindamycin and gentamicin target polymicrobial flora including group B streptococci and anaerobes. Prompt administration reduces risk of sepsis and uterine abscess. Oxytocic agents like oxytocin promote uterine contraction, aiding involution and expulsion of infected lochia. This reduces bacterial load and improves antibiotic penetration.
Rationale for correct parameters Temperature monitoring detects systemic infection progression; normal postpartum range is <38°C. Persistent elevation suggests inadequate response to therapy. Lochia assessment identifies changes in volume and odor; normal lochia rubra transitions to serosa by day 3–4. Foul odor and dark color indicate retained infected tissue.
Rationale for incorrect conditions Deep vein thrombosis presents with unilateral leg pain, warmth, and swelling, absent here. Urinary tract infection causes dysuria, urgency, and suprapubic pain, not present. Engorgement causes bilateral breast fullness and discomfort, but client is bottle-feeding and denies nipple pain.
Rationale for incorrect actions Anticoagulant therapy is irrelevant without thrombotic signs. Fluid intake helps urinary tract infections, not uterine infections. Ice packs treat breast engorgement, not uterine infection.
Rationale for incorrect parameters Nipple integrity relates to breastfeeding complications. Bladder distention is not present and unrelated to uterine infection. Leg circumference monitors DVT, not endometritis.
Take home points:
- Endometritis is a postpartum uterine infection marked by fever, uterine tenderness, and foul lochia.
- Cesarean delivery and prolonged rupture of membranes are major risk factors.
- Management includes antibiotics and uterine contraction support.
- Differentiate from DVT, UTI, and engorgement using targeted signs and history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Phototherapy involves using specific light wavelengths to change unconjugated bilirubin into water-soluble isomers that the newborn can excrete, treating hyperbilirubinemia. Covering the newborn's eyes with an opaque eye shield is crucial to prevent retinal damage from the high-intensity light. The light energy can induce photochemical reactions in the delicate retinal cells, causing injury.
Choice B rationale
Applying lotions, creams, or oils to the newborn's skin is contraindicated during phototherapy. These substances can absorb the light energy, potentially causing burns or skin rashes due to heat concentration and sensitization. The skin should be clean and dry to allow maximum light exposure for bilirubin breakdown.
Choice C rationale
The light used in phototherapy must expose the maximum surface area of the skin to be effective in bilirubin isomerization. Wearing a hat covers a portion of the head's skin surface, which would decrease the therapeutic efficacy of the treatment. The newborn should be exposed, wearing only a diaper for maximum skin exposure.
Choice D rationale
Moving the phototherapy lights closer than the manufacturer's recommended distance, or placing them right against the incubator, could cause hyperthermia (overheating) or potentially burns to the newborn's skin due to increased heat transfer. The lights should be positioned according to the specific unit's protocol to maintain a safe and effective distance.
Correct Answer is D
Explanation
Choice A rationale
Vesicles on the skin, lips, and around the eyes are characteristic findings for a herpes simplex virus (HSV) infection, which is a significant and potentially life-threatening viral infection in a newborn. Candida albicans, a fungus, typically causes superficial mucocutaneous infections and is not associated with vesicular skin lesions unless disseminated, which is rare.
Choice B rationale
A temperature of 37.5°C (99.5°F) is within the normal thermal range for a newborn; normal rectal temperature is 36.5°C to 37.5°C (97.7°F to 99.5°F). While an infection could cause fever, this specific temperature is not necessarily indicative of a Candida infection and is an expected normal finding.
Choice C rationale
Edematous red conjunctivae are classic signs of conjunctivitis (ophthalmia neonatorum), often caused by bacterial pathogens like Chlamydia trachomatis or Neisseria gonorrhoeae, acquired during passage through the birth canal. Candida albicans rarely causes ocular infection unless in immunocompromised infants.
Choice D rationale
White patches on the tongue that cannot be removed with gentle scraping are the pathognomonic sign of oral candidiasis (thrush). This is caused by an overgrowth of the yeast Candida albicans, forming a superficial pseudomembrane composed of yeast, debris, and inflammatory cells on the buccal mucosa and tongue.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.