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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. Smoked salmon: Smoked and aged foods are high in tyramine, which can interact dangerously with phenelzine, a monoamine oxidase inhibitor (MAOI). This interaction can trigger a hypertensive crisis, making smoked salmon a food to avoid during therapy.

B. Cottage cheese: Cottage cheese contains low levels of tyramine compared to aged cheeses and is generally considered safe for clients taking MAOIs like phenelzine. It does not pose a significant risk for hypertensive crisis.

C. Grapefruit: Grapefruit can interact with many medications by affecting liver enzymes, but it does not have a known interaction with phenelzine. The concern with phenelzine is primarily with tyramine-rich foods, not citrus fruits.

D. Spinach: Spinach is not high in tyramine and does not interact with MAOIs. It is a leafy green that is safe and healthy for clients to consume while on phenelzine.

Correct Answer is D

Explanation

Rationale:

A. A client must create a do-not-resuscitate order when completing advance directives: A DNR is a separate medical order and is not required when completing advance directives. Clients may choose to include resuscitation preferences in their directive but are not obligated to.

B. Advance directives cannot be changed once implemented: Advance directives are flexible documents that can be revised or revoked by the client at any time, as long as the client is mentally competent. This allows clients to adjust their wishes as circumstances or preferences change.

C. Assigning a health care surrogate requires legal consultation: While laws vary by state, in most cases, a legal consultation is not required. Clients can designate a surrogate by completing a form that is often available at healthcare facilities or through state-provided templates.

D. A health care surrogate makes health care decisions when the client is no longer able: A surrogate, also known as a durable power of attorney for health care, steps in only when the client loses decision-making capacity. This ensures that the client’s preferences are respected when they cannot communicate them.

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