A nurse on a postpartum unit is caring for a client.
Complete the following sentence by using the lists of options.
The client is most likely experiencing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct choices
• Endometritis: The client presents with multiple risk factors for postpartum uterine infection, including cesarean delivery, prolonged rupture of membranes, and high parity. Clinical findings of uterine tenderness, foul-smelling lochia, fever, and tachycardia are classic for endometritis. The markedly elevated WBC count further supports an infectious process rather than normal postpartum changes.
• Uterus and lochia assessment: The uterus is tender to palpation and positioned above the umbilicus, with lochia that is dark brown and foul-smelling, which is abnormal in the postpartum period. Foul-smelling lochia is a hallmark sign of uterine infection due to bacterial overgrowth. Uterine tenderness reflects inflammation of the endometrial lining.
Rationale for incorrect choices
• Mastitis: Although the client reports breast firmness, warmth, and nipple discomfort, these findings are consistent with normal breast engorgement rather than infection. Mastitis typically presents with localized breast redness, unilateral pain, and systemic symptoms such as chills. The uterine findings and foul-smelling lochia are not associated with mastitis.
• Postpartum hemorrhage: Postpartum hemorrhage is characterized by excessive bleeding, hypotension, and signs of hypovolemia, which are not present in this client. The lochia amount is moderate rather than heavy and the hemoglobin level is stable. Although the fundus was initially boggy, it firmed with massage, indicating uterine tone is responsive.
• WBC: Leukocytosis can occur normally in the postpartum period due to physiologic stress and inflammation. While the WBC count is significantly elevated, it is not specific on its own for diagnosing endometritis. Without supporting uterine and lochia findings, an elevated WBC is not the strongest single piece of evidence for this diagnosis.
• Fever: A mild fever can occur postpartum due to breast engorgement, dehydration, or normal inflammatory responses. Fever alone does not localize the source of pathology or confirm uterine infection. When paired with uterine tenderness and foul-smelling lochia, the diagnosis becomes clearer. On its own, fever is insufficient to make the diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Repeat the dose if your child vomits within 1 hour after taking the medication.": Repeating a dose after vomiting can increase the risk of digoxin toxicity. It is important to notify the healthcare provider rather than automatically administering another dose.
B. "Limit your child's potassium intake while she is taking this medication.": Limiting potassium is unsafe, as low potassium levels increase the risk of digoxin toxicity. Adequate potassium intake should be maintained, and potassium levels monitored, especially if the child is on diuretics.
C. "Have your child drink a small glass of water after swallowing the medication.": Encouraging the child to drink water helps ensure the full dose is swallowed and reduces irritation to the esophagus, promoting safe and effective administration.
D. "You can add the medication to a half-cup of your child's favorite juice.": Digoxin should not be mixed with large volumes of liquid because toddlers may not consume the entire dose, leading to underdosing. Small amounts of liquid can be used to aid administration but must be measured carefully.
Correct Answer is D
Explanation
A. Refer the family to a chronic pain support group: While psychosocial support can be beneficial for children with chronic migraines, referral to a support group is not the priority initial action. The first step is to assess and understand the pattern and triggers of the headaches.
B. Request a change in medication from the provider: Medication adjustments may be necessary, but the nurse must first gather objective and subjective data on the child’s pain patterns, frequency, and triggers before advocating for changes in pharmacologic management.
C. Set up an appointment with the school nurse: Collaborating with the school nurse can help manage migraines during school hours, but this action is secondary to assessing the child’s headache history and current management at home.
D. Review the child's electronic pain diary: Reviewing the electronic pain diary provides detailed, chronological information about headache frequency, intensity, triggers, and response to interventions. This assessment is essential for guiding further interventions and is the first action in clinical decision-making according to the nursing process.
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