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 B
Explanation
A. Physical therapy: Physical therapists focus on improving mobility, balance, and strength. While important after a stroke, they do not primarily address swallowing difficulties.
B. Speech therapy: Speech-language pathologists assess and treat dysphagia (swallowing disorders) and communication difficulties. Referral to speech therapy ensures the client receives appropriate evaluation and interventions to prevent aspiration and maintain nutrition.
C. Respiratory therapy: Respiratory therapists manage airway and pulmonary function issues. They may assist if complications like aspiration pneumonia occur, but they do not directly treat swallowing difficulties.
D. Occupational therapy: Occupational therapists help with activities of daily living and adaptive strategies for self-care. While they may assist with feeding techniques or positioning, they do not specialize in swallowing assessments or interventions.
Correct Answer is C
Explanation
Rationale:
A. "I don't think you understand the risks to your health.": This response is dismissive of the client’s autonomy and implies the nurse is questioning the client’s decision-making ability. It can create a defensive reaction rather than supporting informed consent.
B. "You should talk with your family about it first.": While family support can be helpful, the decision for surgery ultimately rests with the client. Suggesting family involvement at this point could undermine the client’s right to make an independent healthcare decision.
C. "I will notify your provider regarding this decision.": This response respects the client’s autonomy and ensures the healthcare team is promptly informed. It also facilitates further discussion between the provider and client about the decision, ensuring it is fully informed.
D. "Let me remind you of the benefits of the surgery.": While reviewing benefits can be part of informed consent, doing so after the client has expressed a clear decision not to proceed may be perceived as coercive rather than supportive.
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