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":"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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Use a cane for support while walking: A cane can enhance balance and reduce the risk of falls in clients with multiple sclerosis, who may experience muscle weakness, spasticity, or ataxia. It promotes mobility while maintaining safety in the home environment.
B. Avoid the use of orthotics: Orthotic devices, such as ankle-foot orthoses, can actually be helpful in improving gait and preventing foot drop. Advising against their use may deprive the client of important supportive tools.
C. Implement a rigorous range-of-motion exercise plan: While exercise is important, a rigorous plan may lead to fatigue and overheating, which can worsen MS symptoms. A gentle, balanced routine tailored to the client’s tolerance is safer.
D. Walk with feet close together for stability: Keeping the feet close together narrows the base of support and increases fall risk. A wider stance improves balance and stability, which is safer for ambulating clients with MS.
Correct Answer is A
Explanation
Rationale:
A. Frequent swallowing: Frequent swallowing, especially of small amounts, can indicate that the child is swallowing blood from postoperative bleeding. This is a common early sign of hemorrhage following a tonsillectomy and requires immediate evaluation.
B. Increased drowsiness: Drowsiness can result from anesthesia, pain medication, or fatigue after surgery. While it should be monitored, it is not a specific indicator of postoperative hemorrhage in a child following tonsillectomy.
C. Elevated pain level: Pain is expected after tonsillectomy and does not necessarily signal bleeding. Sudden severe pain might warrant reassessment, but elevated pain alone is not a definitive sign of hemorrhage.
D. Diminished breath sounds: Diminished breath sounds are not typically associated with post-tonsillectomy hemorrhage. This finding may indicate a respiratory issue, but not specifically bleeding from the surgical site.
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