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A nurse is caring for the client.

Exhibits

Nurses' Notes

Postpartum Day 3, 0815:

Client reports feeling unwell. Lung sounds clear but diminished in the bases. Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding. Uterus firm at 1 cm above the umbilicus and tender to palpation. Fundus boggy but firmed with massage. Moderate amount of dark brown, foul-smelling lochia noted. Surgical incision well approximated with slight edema present; no signs of infection noted. No bowel movement since birth, hypoactive bowel sounds

Vital Signs

Postpartum Day 3, 0815:

Temperature 38.2° C (100.8° F)

Heart rate 104/min

Respiratory rate 18/min

BP 108/70 mm Hg

SaO2 97% on room air

Diagnostic Results

Postpartum Day 3, 0900:

Hemoglobin 11.1 g/dL

WBC count 33,000/mm3

Uterus firm at 1 cm above the umbilicus and tender to palpation.

Moderate amount of dark brown, foul-smelling lochia noted

Surgical incision well approximated with slight edema present

Temperature 38.2° C (100.8° F)

Respiratory rate 18/min

SaO2 97% on room air

WBC count 33,000/mm3

Answer and Explanation

The Correct Answer is ["A","B","D","G"]

Rationale for Correct Answers:

Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.

A. Provide the client with periods of alone time for reflection on their behavior. B. Discuss strategies with the client to reduce alcohol consumption gradually C. Have the client's partner assume responsibility for monitoring the client's alcohol intake. D. Give positive feedback to the client for using adaptive coping strategies

Correct Answer is D

Explanation

A. Provide the client with periods of alone time for reflection on their behavior: While reflection can be helpful, unsupervised alone time may increase the risk of relapse in clients with alcohol use disorder and does not actively promote self-control.

B. Discuss strategies with the client to reduce alcohol consumption gradually: Gradual reduction is not always safe due to the risk of withdrawal complications. Abstinence under supervision is the recommended approach for alcohol use disorder.

C. Have the client's partner assume responsibility for monitoring the client's alcohol intake: Delegating responsibility to a family member undermines the client’s autonomy and does not foster personal self-control or coping skills.

D. Give positive feedback to the client for using adaptive coping strategies: Reinforcing the use of healthy coping mechanisms encourages self-control, builds confidence, and promotes continued use of adaptive strategies to manage stress without relying on alcohol.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to deal with stress. Which of the following actions should the nurse take to assist the client in maintaining self-control of the behavior?

Correct Answer is D

Explanation

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