A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?

Epigastric discomfort

Flank pain

Temperature 37.7° C (99.8° F)

Abdominal cramping

Answer and Explanation

The Correct Answer is B

Rationale:

A. Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.

B. Flank pain is a common manifestation of pyelonephritis, which is an infection of the kidneys.

Clients with pyelonephritis often experience pain in the flank area, which is located between the lower ribs and the pelvis, on one or both sides of the body.

C. A temperature of 37.7°C (99.8°F) may indicate a low-grade fever, which can be present in pyelonephritis due to the body's immune response to infection.

D. Abdominal cramping may occur with various conditions during pregnancy but is not specific to pyelonephritis.

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Correct Answer is B

Explanation

Rationale:

A. Administering broad-spectrum antibiotics is not indicated as the first-line intervention for a myelomeningocele that is leaking cerebrospinal fluid. Antibiotics may be initiated later if signs of infection develop.

B. Cleansing the site with povidone-iodine is essential to reduce the risk of infection and prevent contamination of the exposed neural tissue.

C. Monitoring the rectal temperature every 4 hours is important for assessing the newborn's overall health but is not specific to managing a myelomeningocele.

D. Surgical closure of the myelomeningocele may be necessary, but immediate care focuses on protecting the exposed neural tissue and preventing infection before surgical intervention.

A. Insert a urinary catheter. B. Assist the client to the bathroom. C. Offer the client a sitz bath. D. Pour warm water over the client's perineum.

Correct Answer is B

Explanation

Rationale:

A. Inserting a urinary catheter is an invasive procedure and should not be the first action taken to address bladder distention following a vaginal birth. It should only be considered if the client is unable to void voluntarily.

B. Assisting the client to the bathroom is the initial intervention to attempt to relieve bladder distention. Encouraging the client to void in a comfortable and familiar environment may stimulate urination and help alleviate the distention.

C. Offering the client a sitz bath may provide comfort and promote perineal healing but is not the first intervention for bladder distention.

D. Pouring warm water over the client's perineum may also provide comfort but does not directly address bladder distention.

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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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