A nurse is collecting data from a client who is 2 days postpartum. Which of the following findings should alert the nurse to the possibility of a puerperal infection?

Upper abdominal pain

Bradycardia

Hypothermia

Foul-smelling lochia

Answer and Explanation

The Correct Answer is D

A.   Upper abdominal pain could indicate a variety of issues, including gastrointestinal upset or muscle soreness from labor, but it is not specific to a puerperal infection.
B.   Bradycardia (slow heart rate) is not typically associated with a puerperal infection.
C.   Hypothermia (low body temperature) is not a typical sign of a puerperal infection.
D.   Foul-smelling lochia can be indicative of an infection, as an unpleasant odor may be associated with bacterial growth in the uterine cavity. This is a concerning sign and should be further evaluated.

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Correct Answer is A

Explanation

A. Applying a warm pack to the puncture site before the procedure increases blood flow to the area, which makes the blood sample collection easier and reduces discomfort for the newborn.

B. A mummy restraint may not be necessary for a routine blood glucose test. The nurse can gently hold the newborn in place during the procedure without needing to fully restrain them.

C. Antiseptic solution is typically applied before the puncture to cleanse the area. After the procedure, gentle pressure and bandaging are more appropriate to stop bleeding.

D. Elevating the extremity is unnecessary for a newborn blood glucose test, as warming the area is more effective in promoting blood flow to the puncture site.

A. Apply elastic stockings before the client gets out of bed. B. Apply warm, moist packs to the client's lower legs. C. Have the client ambulate as often as possible. D. Administer NSAIDs every 4 to 6 hours.

Correct Answer is C

Explanation

A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.

B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.

C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.

D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.

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A nurse is collecting data from a client who is 2 days postpartum. Which of the following findings should alert the nurse to the possibility of a puerperal infection?

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Naxlex Comprehensive Predictor Exams

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