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
Elevated maternal serum alpha-fetoprotein (MSAFP) levels can suggest a neural tube defect (NTD), such as spina bifida or anencephaly. Alpha-fetoprotein is a glycoprotein produced by the fetal liver and yolk sac. With an open NTD, this protein leaks from the exposed fetal tissue into the amniotic fluid and subsequently crosses the placenta into the maternal bloodstream, causing the observed elevation.
Choice B rationale
Trisomy 21 (Down syndrome) is typically associated with lower than normal MSAFP levels. MSAFP is part of the quad screen (or triple screen) that screens for common chromosomal abnormalities. Low levels of MSAFP, often combined with abnormal levels of other markers like β-hCG, unconjugated estriol, and inhibin A, suggest an increased risk for this aneuploidy.
Choice C rationale
Phenylketonuria (PKU) is an inherited metabolic disorder where the body cannot properly metabolize the amino acid phenylalanine due to a deficiency of the enzyme phenylalanine hydroxylase. It is not directly associated with elevated MSAFP levels. PKU is screened for in newborns via a heel stick blood test, usually 24 to 48 hours after birth.
Choice D rationale
Hemophilia is an X-linked recessive bleeding disorder caused by a deficiency in specific clotting factors, typically factor VIII (Hemophilia A) or factor IX (Hemophilia B). This condition involves defective hemostasis and is not indicated by an elevated MSAFP. Hemophilia is often diagnosed through specific clotting factor assays.
Correct Answer is A
Explanation
Choice A rationale
Applying witch hazel compresses (such as Tucks pads) is an effective and preferred action for postpartum perineal discomfort, including episiotomy pain. Witch hazel contains tannins and volatile oils that provide an astringent and anti-inflammatory effect. This action helps to reduce swelling, soothe the tissues, and offer immediate, localized pain relief at the episiotomy site.
Choice B rationale
Administering aspirin (acetylsalicylic acid) for postpartum discomfort is generally contraindicated. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) with antiplatelet effects, which could increase the risk of bleeding postpartum, especially from the placental insertion site or the episiotomy wound. Preferred analgesics are typically acetaminophen or ibuprofen, which have less impact on coagulation.
Choice C rationale
Having the client use a warm pack is not the initial treatment for episiotomy pain within the first 24 hours. Heat promotes vasodilation, which can increase edema and pain in the acutely inflamed and traumatized tissues. Cold therapy (e.g., ice packs) is the standard initial treatment because it causes vasoconstriction, which minimizes swelling and provides a local anesthetic effect.
Choice D rationale
Instructing the client to sit on a soft pillow might seem helpful, but it can sometimes be detrimental. Sitting on a soft, ring-shaped, or inflated pillow can cause the client to press outward on the soft tissues of the perineum, potentially increasing pressure and discomfort on the episiotomy incision. Sitting on a firm surface with the buttocks shifted can be more comfortable for some.
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