A nurse is collecting data from a client who gave birth one week ago. Which of the following findings should the nurse identify as a manifestation of endometritis?
Hematuria
Pelvic pain
Pink lochia
Bradycardia
The Correct Answer is B
Choice A reason: Hematuria is blood in the urine. It is not a symptom of endometritis, which is an inflammation or infection of the uterine lining. Hematuria can have many other causes, such as urinary tract infections, kidney stones, bladder cancer, or trauma.
Choice B reason: Pelvic pain is one of the most common symptoms of endometritis. It can be caused by the inflammation or infection of the uterine lining, which can also spread to other pelvic organs. Pelvic pain can be dull, sharp, cramping, or constant, and it may worsen with movement or intercourse¹³.
Choice C reason: Pink lochia is normal vaginal discharge after childbirth. It consists of blood, mucus, and tissue from the uterus. It usually lasts for a few weeks and gradually changes color from red to pink to brown to white. Pink lochia is not a sign of endometritis, unless it is foul-smelling, heavy, or persists beyond six weeks.
Choice D reason: Bradycardia is a slow heart rate, usually below 60 beats per minute. It is not a symptom of endometritis, which can cause fever and tachycardia (fast heart rate). Bradycardia can have many other causes, such as heart disease, medication side effects, hypothyroidism, or electrolyte imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Check the client's temperature every 4 hr is incorrect, as this action is not frequent enough for a client who had an amniotomy. The nurse should check the client's temperature every 2 hr after an amniotomy, as there is an increased risk of infection due to the rupture of membranes. The nurse should also monitor for signs of chorioamnionitis, such as foul-smelling amniotic fluid, maternal tachycardia, or fetal tachycardia.
Choice B reason: Remind the client to bear down with each contraction is incorrect, as this action is not appropriate for a client who is in the active phase of the first stage of labor. The nurse should instruct the client to avoid bearing down or pushing until they are in the second stage of labor, when the cervix is fully dilated and effaced. Bearing down too early can cause cervical edema, lacerations, or exhaustion.
Choice C reason: Maintain the client in the lithotomy position is incorrect, as this action is not optimal for a client who is in the active phase of the first stage of labor. The lithotomy position is a supine position with the legs elevated and abducted, which can reduce blood flow to the uterus and placenta, increase perineal edema, and limit pelvic outlet diameter. The nurse should encourage the client to change positions frequently and use upright or lateral positions that can enhance uterine contractility, fetal descent, and maternal comfort.
Choice D reason: Encourage the client to empty the bladder every 2 hr is correct, as this action can promote labor progress and prevent bladder distension and infection. The nurse should assist the client to void every 2 hr after an amniotomy, as there may be decreased sensation of bladder fullness due to pressure from the fetal head. A full bladder can interfere with uterine contractions, fetal descent, and cervical dilation.
Correct Answer is D
Explanation
Choice D reason:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take, as it can relieve pressure on the cord and prevent compression and fetal hypoxia. The nurse should also use a sterile gloved hand to hold the presenting part off the cord.
Choice A reason:
Preparing the client for an emergency cesarean birth is an important action, as it can facilitate prompt delivery and prevent fetal compromise. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.
Choice B reason:
Covering the cord with a sterile, moist saline dressing is an important action, as it can prevent drying and infection of the cord. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord compression.
Choice C reason:
Explaining to the client what is happening is an important action, as it can provide emotional support and education for the client. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.
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