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A nurse on a postpartum unit is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The client is most likely experiencing

as evidenced by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for Correct Choices

  • Endometritis: This uterine infection is common after cesarean delivery, especially with prolonged rupture of membranes. The client’s uterine tenderness, elevated fundus, boggy consistency, and foul-smelling lochia are hallmark signs of endometritis, making it the most likely diagnosis.
  • Uterus and lochia: The presence of a tender uterus that is elevated above the umbilicus and only firms with massage, combined with dark, malodorous lochia, strongly suggests infection of the uterine lining. These findings point specifically to endometritis rather than general postpartum changes.

Rationale for Incorrect Choices

  • Mastitis: Although the client reports heavy, warm breasts with nipple discomfort, there is no breast erythema, localized swelling, or high-grade fever typical of mastitis. These symptoms are likely due to engorgement related to lactation rather than infection.
  • Pneumonia: The client’s respiratory assessment shows clear lungs with only slight basal changes common postoperatively. There are no signs of cough, sputum production, hypoxia, or respiratory distress, which makes pneumonia an unlikely cause of her symptoms.
  • Fever: A temperature of 38.2°C is above normal, but mild postpartum fever can have various causes, including engorgement, dehydration, or early infection. Fever alone is not specific enough to confirm a diagnosis without targeted findings.
  • WBC count: Although an elevated WBC of 33,000/mm³ raises concern, postpartum leukocytosis can be physiologic or related to many infections. It is not diagnostic of endometritis without more specific correlating signs like uterine tenderness and abnormal lochia.


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Related Questions

Correct Answer is A

Explanation

Rationale:

A. Explain to the client they can change their mind at any time: Clients have the right to make or revoke decisions about resuscitation at any time. Informing the client of this autonomy supports informed consent and respects their evolving preferences and values regarding end-of-life care.

B. Obtain consent from the family for the change to the plan of care: The decision for a Do Not Resuscitate (DNR) order is made by the client, not the family, if the client is competent. Family involvement is supportive but does not override the client’s autonomy in this matter.

C. Discharge the client to hospice care: While hospice may be appropriate for end-stage disease, requesting a DNR does not automatically necessitate discharge. Clients can remain in the current care setting with appropriate adjustments to their goals of care.

D. Place a sign with "Do Not Resuscitate" outside the client's room: Displaying such signs can violate privacy and confidentiality. Instead, the DNR order should be documented clearly in the medical record and care plan, accessible to the healthcare team.

Correct Answer is C

Explanation

Rationale:

A. "I will remove gluten from my diet.": Gluten is unrelated to latex allergies. It is typically avoided in conditions like celiac disease, but does not cross-react with latex proteins and is not a concern for latex-sensitive individuals.

B. "I will remove peanuts from my diet.": Although peanut allergies are common, there is no significant cross-reactivity between peanuts and latex. Avoiding peanuts is not necessary unless the client has a separate peanut allergy.

C. "I will remove bananas from my diet.": Bananas contain proteins similar to those found in natural latex. Clients with latex allergies often have cross-reactive food allergies, especially to bananas, avocados, kiwis, and chestnuts this is known as latex-fruit syndrome.

D. "I will remove dairy products from my diet.": Dairy products are not associated with latex sensitivity. Removing them offers no protective benefit for clients with a latex allergy unless a separate dairy intolerance or allergy exists.

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