A nurse is providing care to multiple clients on the postpartum unit.
Which of the following clients is at the greatest risk for developing a puerperal infection?
A client who has a cesarean incision that is well-approximated with no drainage.
A client who does not wash her hands between perineal care and breastfeeding.
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration.
A client who is not breastfeeding and is using measures to suppress lactation.
The Correct Answer is C
Choice A rationale
A client who has a cesarean incision that is well-approximated with no drainage is not at the greatest risk for developing a puerperal infection. While any surgical incision can potentially become infected, if the incision is healing well with no signs of infection, the risk is relatively low.
Choice B rationale
A client who does not wash her hands between perineal care and breastfeeding is increasing her risk of infection, but this is not the greatest risk factor for developing a puerperal infection. Good hand hygiene is important to prevent the spread of germs, but other factors pose a greater risk for puerperal infection.
Choice C rationale
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration is at the greatest risk for developing a puerperal infection. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. If the episiotomy extends and becomes a third-degree laceration, it involves the vaginal tissue, perineal skin, and the muscle of the perineum, and can extend into the anal sphincter, the muscle that surrounds the anus. This type of wound provides a medium for bacterial growth, increasing the risk of infection.
Choice D rationale
A client who is not breastfeeding and is using measures to suppress lactation is not at the greatest risk for developing a puerperal infection. While breastfeeding can help reduce the risk of certain types of infections, not breastfeeding does not significantly increase the risk of puerperal infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hydration is crucial for children who have recovered from an acute crisis episode of sickle cell anemia. Dehydration can increase the risk of a sickle cell crisis by making the blood more concentrated. Offering fluids to the child multiple times every day can help prevent dehydration.
Choice B rationale
Monitoring the child’s temperature daily can help detect any infections early. Infections can trigger a sickle cell crisis. However, this is not the most critical instruction for the nurse to include in the teaching.
Choice C rationale
Applying cold compresses when the child expresses pain is not recommended. Cold can cause vasoconstriction, which can lead to a decrease in blood flow and potentially trigger a sickle cell crisis.
Choice D rationale
Restricting outdoor play activity to 1 hour per day is not necessarily required for children who have recovered from an acute crisis episode of sickle cell anemia. Physical activity is generally beneficial for children’s health and well-being.
Correct Answer is B
Explanation
Choice A rationale
While inserting an IV catheter can be a part of the overall management plan for a client showing late decelerations on the electronic fetal monitor, it is not the initial course of action. The primary concern with late decelerations is that they may indicate fetal hypoxia, and the first response should be aimed at improving fetal oxygenation.
Choice B rationale
Assisting the client into the left-lateral position is the correct initial response when late decelerations are observed on the electronic fetal monitor. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Choice C rationale
Applying a fetal scalp electrode may be useful for obtaining a more accurate fetal heart rate tracing, but it is not the initial response to late decelerations. The priority is to address the potential fetal hypoxia that late decelerations may indicate.
Choice D rationale
Performing a vaginal exam would not be the initial response to late decelerations. While a vaginal exam can provide valuable information about the progress of labor, it does not address the issue of potential fetal hypoxia indicated by late decelerations.
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