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A nurse is caring for a postpartum female client who gave birth 3 days ago in a hospital setting.

Exhibits

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 evaluate the client’s progress.

Answer and Explanation

The Correct Answer is []

Based on the provided information, here’s the completed diagram:

Potential Condition

  • D. Endometritis

Actions to Take

  • A. Administer broad-spectrum antibiotics
  • D. Administer analgesics

Parameters to Monitor

  • A. Lochia amount and odor
  • B. Temperature

Explanation of Other Conditions

  1. Deep vein thrombosis (DVT):
    • Reasoning: The client has bilateral edema without pain, warmth, or tenderness, which are typical signs of DVT. Additionally, the primary symptoms (malaise, chills, fever, foul-smelling lochia) are more indicative of an infection like endometritis.
  2. Urinary tract infection (UTI):
    • Reasoning: The client is voiding frequently without difficulty, and there are no specific urinary symptoms like dysuria or urgency. The presence of foul-smelling lochia and a boggy, tender uterus points more towards endometritis.
  3. Engorgement:
    • Reasoning: While the client’s breasts are firm and heavy, she denies nipple discomfort, and the primary symptoms (fever, chills, malaise, foul-smelling lochia) are more consistent with an infection rather than simple breast engorgement.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale

Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.

Choice B rationale

Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.

Choice C rationale

The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.

Choice D rationale

Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

  1. Perform a Nitrazine test:Anticipated. This test helps confirm if the membranes have ruptured, which is consistent with the client’s report of fluid leakage.
  2. Ensure the client maintains a supine position:Contraindicated. Prolonged supine positioning can reduce blood flow to the fetus and cause maternal hypotension. It’s better to encourage side-lying positions.
  3. Prepare the client for catheterization:Nonessential. The client is able to void on her own, so catheterization isn’t necessary at this point.
  4. Check client’s temperature every hour:Anticipated. Regular temperature checks are important to monitor for signs of infection, especially after membrane rupture.
  5. Encourage frequent ambulation:Anticipated. Ambulation can help progress labor and is generally encouraged if there are no contraindications.
  6. Obtain CBC blood sample:Anticipated. A CBC can provide important information about the client’s overall health and detect any potential issues like infection or anemia.
  7. Check FHR every 30 min:Anticipated. Regular monitoring of the fetal heart rate is crucial to ensure the well-being of the fetus during labor.

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