A nurse is monitoring a patient who had a cesarean delivery for signs of infection.
Which of the following findings should alert the nurse to a possible infection? (Select all that apply.).
Temperature of 38°C (100.4°F) or higher
Foul-smelling lochia or increased lochia
Tenderness or hardness in the lower abdomen
Decreased white blood cell count
Increased thirst or dry mouth
Correct Answer : A,B
The correct answer is choice A and B. A temperature of 38°C (100.4°F) or higher and foul-smelling lochia or increased lochia are signs of infection after a C-section. A C-section is a major surgery that involves making incisions in the abdomen and uterus, which can get infected by bacteria. An infection can also affect the lining of the uterus (endometritis) or the urinary tract.
Choice C is wrong because tenderness or hardness in the lower abdomen is normal after a C-section and does not indicate an infection.
Choice D is wrong because a decreased white blood cell count is not a sign of infection. In fact, an increased white blood cell count is more likely to occur with an infection.
Choice E is wrong because increased thirst or dry mouth is not a sign of infection. It could be due to dehydration, medication, or hormonal changes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A) Administering prophylactic antibiotics as ordered.According to the WHO guidelines for the prevention of surgical site infection (SSI), prophylactic antibiotics should be given within 60 minutes before skin incision and discontinued within 24 hours after surgery.
This reduces the risk of SSI by preventing bacterial colonization of the surgical site.
Choice B) Encouraging coughing and deep breathing exercises is wrong because this intervention is mainly for preventing respiratory complications, not SSI.Coughing and deep breathing exercises help to clear secretions and prevent atelectasis and pneumonia.
Choice C) Providing adequate pain control is wrong because this intervention is mainly for improving patient comfort and recovery, not SSI.Pain control may reduce stress and inflammation, but it does not directly affect the risk of SSI.
Choice D) Assessing for signs of deep vein thrombosis (DVT) is wrong because this intervention is mainly for preventing venous thromboembolism (VTE), not SSI.
DVT is a condition where a blood clot forms in a deep vein, usually in the legs.
It can cause pain, swelling, and redness.If the clot breaks off and travels to the lungs, it can cause a pulmonary embolism (PE), which can be life-threatening.
Some other intraoperative interventions for preventing SSI include using an alcohol-based skin prep, maintaining body temperature, using impervious wound protectors, and performing SSI surveillance.
Correct Answer is B
Explanation
The correct answer is choice B. The client can use patient-controlled analgesia to self-administer opioids.This is a form of multimodal analgesia, which is the core principle for cesarean delivery pain management.
Patient-controlled analgesia allows the client to have control over their pain relief and adjust the dose according to their needs.
Choice A is wrong because the client may experience delays in receiving analgesics if they have to request them from the nurse, which can lead to inadequate pain relief and increased opioid consumption.
Choice C is wrong because ice packs are not recommended for cesarean delivery pain management, as they may interfere with wound healing and increase the risk of infection.
Choice D is wrong because deep breathing and relaxation exercises are not sufficient to manage acute postoperative pain, although they may be helpful as adjuncts to pharmacologic methods.
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