A nurse is caring for the client.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer fluid bolus immediately when the client arrives to the facility: Rapid fluid boluses are reserved for clients in hypovolemic shock. For burn resuscitation, fluids are calculated and administered according to formulas rather than as a one-time bolus.
B. Administer one-third of the total fluid volume for resuscitation within the first 12 hr: Burn fluid resuscitation formulas, such as the Parkland formula, typically require half of the total calculated fluids to be given within the first 8 hours post-burn, not 12 hours.
C. Calculate fluid volume for resuscitation beginning with client arrival time at the facility: Fluid calculation is based on the time of the burn occurrence, not the arrival time, to ensure accurate resuscitation over the initial 24 hours.
D. Use the total body surface area of the client's burns when calculating fluid volume for resuscitation: The extent of burns, expressed as a percentage of total body surface area (TBSA), is a key factor in calculating fluid needs. Accurate TBSA assessment ensures appropriate fluid resuscitation to maintain perfusion and prevent complications.
Correct Answer is A
Explanation
Rationale:
A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.
B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.
C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.
D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.
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