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
Practicing Kegel exercises is a common recommendation for postpartum women experiencing urinary incontinence. Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum. Strengthening these muscles can help control urinary incontinence.
Choice B rationale
Abdominal crunches are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice C rationale
Similar to abdominal crunches, sit-ups are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice D rationale
While pelvic tilt exercises can be beneficial for postpartum women, they are not specifically targeted at improving urinary incontinence.
Correct Answer is A
Explanation
Choice A rationale
The statement “I only need to catheterize myself twice every day” should alert the nurse to the need for further education. Individuals with spina bifida who are paralyzed from the waist down often need to perform clean intermittent catheterization (CIC) every 3-4 hours to empty the bladder and prevent urinary tract infections.
Choice B rationale
Using a suppository every night to have a bowel movement is a common practice among individuals with spina bifida. Due to the paralysis, they often have difficulty with bowel movements and may use suppositories or other methods to stimulate bowel movements.
Choice C rationale
Doing wheelchair exercises while watching TV is a good practice for individuals with spina bifida. Regular physical activity can help improve strength, flexibility, and overall health.
Choice D rationale
Carrying a water bottle and drinking a lot of water is a good practice for individuals with spina bifida. Adequate hydration can help prevent urinary tract infections and kidney stones, which are common complications in individuals who perform CIC78910.
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