A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
Midline episiotomy
Meconium-stained fluid
Gestational hypertension
Placenta previa
The Correct Answer is A
A. A midline episiotomy is a surgical incision made in the perineal area during childbirth. It is recognized as a risk factor for postpartum infection due to the possibility of bacterial contamination during and after delivery. Proper care and monitoring are essential to prevent infection in the site of the incision.
B. meconium-stained fluid, is not typically a risk factor for maternal infection; it is more a concern for the infant's health if aspirated.
C. gestational hypertension, affects blood pressure during pregnancy but does not directly increase the risk of postpartum infection.
D. placenta previa, is a condition where the placenta covers the cervix, which can lead to bleeding but not infection. Therefore, among the given options, a midline episiotomy is the factor that most significantly places the postpartum client at risk for an infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The Babinski reflex is a normal reflex present in newborns and infants up to about 2 years old. It is elicited by stroking the lateral aspect of the sole of the foot from the heel towards the toes. A positive Babinski reflex is characterized by dorsiflexion (upward movement) of the big toe and fanning out of the other toes. This is also known as an extensor response.
Therefore, option a, eversion of the great toe, is the expected finding for a positive Babinski reflex. Options b, c, and d are not consistent with a positive Babinski reflex.
Correct Answer is B
Explanation
Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.
Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.
Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.
Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.
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