A nurse is caring for the client.
Temperature
Hgb
Heart rate
Fundal height
Lochia
WBC count
Correct Answer : A,C,D,E,F
Rationale:
A. Temperature: The client's temperature decreased from 38.6°C (101.5°F) to 37.1°C (98.9°F), indicating that the febrile response to infection has resolved. This trend supports the effectiveness of the antibiotic therapy initiated on postpartum day 3.
B. Hgb: Hemoglobin dropped from 11.1 to 10 g/dL, which may reflect continued postpartum blood loss or hemodilution. This decline does not indicate improvement and may require monitoring for worsening anemia.
C. Heart rate; Heart rate improved from 110/min to 78/min, demonstrating reduced physiologic stress and better cardiovascular stability. This aligns with the drop in temperature and suggests systemic recovery from infection.
D. Fundal height; The fundus decreased from 1 cm above the umbilicus to 4 cm below, showing normal postpartum involution. A firm, midline uterus without excessive tenderness also supports clinical improvement.
E. Lochia: Lochia changed from moderate, dark brown, and foul-smelling to a small amount of brownish-red with no odor, which suggests resolving endometrial infection. This progression is typical in healthy postpartum recovery.
F. WBC count: The WBC count normalized from 33,000/mm³ to 10,000/mm³, reflecting resolution of systemic inflammation or infection. This is consistent with decreasing temperature and improved vital signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Assist the client to ambulate: Ambulation is encouraged after a laparoscopic cholecystectomy to stimulate peristalsis and help relieve abdominal distention caused by retained gas from insufflation during the procedure. It promotes bowel movement and absorption of gas, improving comfort.
B. Prepare the client for a paracentesis: Paracentesis is used to remove fluid from the peritoneal cavity, typically in clients with ascites or severe fluid retention. Abdominal distention after this procedure is usually due to gas, not fluid.
C. Insert a rectal suppository: Suppositories may stimulate bowel movements but are not the first-line intervention for post-laparoscopic gas-related distention. Encouraging natural movement through ambulation is more effective and less invasive initially.
D. Place the client in the prone position: The prone position is not typically used for relieving abdominal distention. It may cause discomfort and does not aid in gas movement through the intestines as effectively as upright or walking positions.
Correct Answer is B
Explanation
Rationale:
A. "Remove a plug from the socket by pulling the cord": Yanking the cord can damage the cord, loosen wiring, and increase the risk of sparks or electrical fire. The correct method is to grasp the plug firmly and pull it straight out to avoid strain on the wire connections.
B. "Use three-pronged grounded plugs": Three-pronged plugs provide a grounding mechanism that reduces the risk of electric shock and fire. Grounded outlets redirect excess electricity safely into the ground if a fault occurs, making them a key part of electrical safety.
C. "Check for a tingling sensation around the cord": A tingling sensation can indicate an electrical short or exposed wiring, which is a serious safety hazard. While it’s important to report and stop using such cords, the focus should be on prevention before such issues arise.
D. "Cover extension cords with a rug": Covering cords with rugs can trap heat, cause insulation to wear down, and increase fire risk. Cords should be left uncovered and positioned to avoid foot traffic while maintaining ventilation to prevent overheating.
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