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. Educate a client about the purpose of a sputum specimen: Client education requires nursing knowledge and judgment to explain procedures, answer questions, and evaluate understanding. This cannot be delegated to assistive personnel.
B. Perform irrigation of an indwelling urinary catheter: Catheter irrigation is a sterile invasive procedure that requires nursing skill to prevent infection and complications. It falls outside the scope of assistive personnel.
C. Administer liquid aspirin to a client who is crying: Medication administration involves assessment, calculation, and monitoring for adverse effects, which are responsibilities of a licensed nurse. Assistive personnel cannot administer medications.
D. Provide a bed bath for a client who requires isolation precautions: Assisting with hygiene is within the scope of assistive personnel. They can safely provide a bed bath while following isolation protocols under the supervision of the nurse.
Correct Answer is A
Explanation
Rationale:
A. Increased creatinine: Chronic kidney disease reduces the kidneys’ ability to filter waste products effectively, causing creatinine to accumulate in the blood. Elevated creatinine is a key indicator of declining renal function and is expected in this condition.
B. Increased calcium: Clients with chronic kidney disease often have decreased calcium levels due to impaired vitamin D activation and phosphate retention. Increased calcium would be unusual unless the client is receiving supplementation.
C. Increased bicarbonate: Metabolic acidosis is common in chronic kidney disease because the kidneys cannot adequately excrete hydrogen ions or reabsorb bicarbonate. This typically results in decreased, not increased, bicarbonate levels in the blood.
D. Increased hemoglobin: Anemia frequently occurs in chronic kidney disease due to reduced erythropoietin production by the kidneys. This leads to lower hemoglobin levels, so an increase would not be expected unless treated with erythropoiesis-stimulating agents.
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