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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: The cervix is eﬀaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical eﬀacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.

Choice B reason: The cervix is dilated 3 cm, it is eﬀaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, eﬀacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.

Choice C reason: The cervix is eﬀaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical eﬀacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.

Choice D reason: The cervix is dilated 3 cm, it is eﬀaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.

A. Apply warm, moist soaks to the client's lower legs. B. Have the client ambulate frequently in the hallway. C. Keep the client on bed rest. D. Place pillows under the client's knees while she is resting in bed.

Correct Answer is B

Explanation

Choice A reason: Apply warm, moist soaks to the client's lower legs is incorrect, as this action is not eﬀective for preventing thrombophlebitis. Warm, moist soaks can provide comfort and reduce inﬂammation, but they do not improve blood circulation or prevent clot formation.

Choice B reason: Have the client ambulate frequently in the hallway is correct, as this action can prevent thrombophlebitis by improving venous return and preventing stasis. The nurse should encourage and assist the client to ambulate early and frequently after a cesarean birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.

Choice C reason: Keep the client on bed rest is incorrect, as this action can increase the risk of thrombophlebitis by reducing blood ﬂow and promoting stasis. Bed rest can also delay wound healing and increase the risk of infection and deconditioning. The nurse should avoid keeping the client on bed rest unless absolutely necessary.

Choice D reason: Place pillows under the client's knees while she is resting in bed is incorrect, as this action can impair blood circulation and increase the risk of thrombophlebitis. Placing pillows under the knees can cause pressure on the popliteal veins and reduce venous return. The nurse should advise the client to avoid crossing their legs or placing pillows under their knees while resting in bed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Correct Answer is B

Explanation

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