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 C
Explanation
Choice A rationale
Relating the newborn to oneself is a normal process during the "taking-hold" phase of maternal role attainment, typically occurring 2-10 days postpartum, where the mother focuses on the infant and parental role. This involves identifying the newborn as a separate individual while making comparisons, which is an expected psychosocial milestone and not indicative of a concern.
Choice B rationale
Postpartum fatigue and a desire to sleep are common physiological and psychological responses due to the physical exertion of labor, blood loss (normal postpartum blood loss is ≤ 500 mL for vaginal delivery), and interrupted sleep patterns. This is an expected finding and reflects the body's need for rest and recovery, not a pathological psychosocial concern within 48 hours.
Choice C rationale
The absence of desire to feed the newborn or a lack of interest in the infant can be an early indicator of postpartum blues or a more severe mood disorder like postpartum depression. Postpartum blues peaks around day five and resolves within two weeks, but a strong disinterest requires further assessment as it affects bonding and infant care.
Choice D rationale
Discussing the desire for future children indicates a healthy anticipation of a continued family life and is a sign of good adjustment and optimism regarding the maternal role and relationship. This finding is reassuring and signifies positive psychological adaptation rather than a postpartum psychosocial concern within this early timeframe.
Correct Answer is B
Explanation
Choice A rationale
Applying warm packs during the initial 24 hours postpartum is generally contraindicated for an episiotomy site. Heat promotes vasodilation, which could increase swelling and edema in the traumatized perineal tissues, exacerbating pain and potentially increasing blood loss. Cold therapy, such as ice packs, is the preferred intervention initially, as it causes vasoconstriction, reducing localized edema and numbing the area for pain relief.
Choice B rationale
Encouraging the client to take a sitz bath twice daily is an appropriate intervention for an episiotomy, typically after the first 24 hours postpartum when the initial swelling has subsided. The warm water promotes vasodilation, which improves circulation to the perineal area. This enhanced blood flow facilitates healing and offers soothing relief from pain and discomfort, aiding in tissue regeneration and cleanliness.
Choice C rationale
Applying antibiotic ointment to a routine episiotomy is generally not recommended unless there are signs of infection or a specific prescription is provided. The wound is clean, and the risk of introducing pathogens outweighs the routine benefit. Proper hygiene with cleansing after elimination, using a peri-bottle with warm water, and changing pads frequently is the standard of care to prevent infection and promote natural healing.
Choice D rationale
Instructing the client to wipe the perineum with toilet tissue after voiding is incorrect and can be detrimental to episiotomy healing. Wiping, particularly from back to front, can introduce fecal bacteria into the episiotomy site or vagina, increasing the risk of infection. The client should be instructed to use a peri-bottle filled with warm water to gently rinse the area after elimination and then pat dry with a clean cloth or tissue.
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