A nurse is caring for the client.
Temperature
Hgb
Heart rate
Fundal height
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 D
Explanation
Rationale:
A. Use passive listening techniques during conflict resolution: Passive listening involves minimal engagement and can lead to misunderstandings or missed key concerns. Active listening is more effective in conflict resolution as it validates feelings and clarifies perspectives.
B. Ask closed-ended questions about the conflict: Closed-ended questions limit the depth of responses and may not fully uncover the underlying issues. Open-ended questions encourage dialogue and help reveal the root causes of conflict more effectively.
C. Ensure each individual can respond defensively about the conflict: Allowing or encouraging defensive responses can escalate tension and hinder resolution. A nonjudgmental and respectful environment promotes open communication and constructive problem-solving.
D. Gather individual information regarding the conflict: Collecting information from each party separately allows the nurse manager to understand different perspectives, identify miscommunications, and develop a balanced and informed approach to resolving the conflict.
Correct Answer is A
Explanation
Rationale:
A. Use a powered lift to transfer the client: When a client is unable to assist and weighs significantly over standard lifting limits, a powered mechanical lift is the safest and most appropriate method. It reduces the risk of musculoskeletal injury to staff and ensures safe, controlled client movement.
B. Wrap their arms under the client's axilla to transfer the client: This manual lifting method can cause harm to both the nurse and the client. It increases the risk of shoulder injury for the client and back strain for the nurse, especially when the client is immobile and heavy.
C. Use a gait belt to transfer the client: Gait belts are used for clients who can bear some weight and assist in the transfer. Since this client cannot assist, a gait belt is insufficient and may result in injury or unsafe movement.
D. Use a sliding board to transfer the client: Sliding boards are typically used when clients have upper body strength and can assist in shifting their weight. For a fully dependent client of this size, it is not a safe or effective method without mechanical assistance.
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