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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 and
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}

  • Endometritis – This uterine infection is one of the most common postpartum complications, especially following cesarean delivery and prolonged rupture of membranes. It often presents with foul-smelling lochia, uterine tenderness, and systemic signs of infection like fever and leukocytosis. This client’s presentation, including foul-smelling lochia and a WBC of 33,000/mm³, strongly supports this diagnosis.
  • Mastitis – Typically associated with localized breast pain, redness, swelling, and systemic symptoms like fever. While the client has nipple discomfort and firm breasts, these are common postpartum findings during milk let-down and do not meet the criteria for mastitis, especially without signs of inflammation or localized breast infection.
  • Pulmonary embolism – A PE generally presents with sudden-onset chest pain, dyspnea, tachypnea, and hypoxia. This client’s oxygen saturation is normal, lung sounds are clear, and there is no respiratory distress, making PE unlikely.
  • Postpartum hemorrhage – Hemorrhage would present with excessive vaginal bleeding, hypotension, tachycardia, and possibly uterine atony. This client’s uterus is firm, lochia is moderate (not heavy), and vital signs are stable, so hemorrhage is not supported by the data.
  • Lochia assessment – Foul-smelling lochia is a classic indicator of uterine infection. It points to endometritis when found with other risk factors like cesarean birth, prolonged labor, and signs of systemic inflammation.
  • Elevated white blood cell count – A postpartum WBC count may be mildly elevated, but a level of 33,000/mm³ suggests infection. When combined with clinical symptoms like uterine tenderness and malodorous discharge, it supports a diagnosis of endometritis.
  • Firm uterus at 1 cm above umbilicus – This finding is expected on postpartum day 3 and indicates normal uterine involution. A firm uterus rules out uterine atony and is not specific to infection or hemorrhage.
  • Moderate nipple discomfort – Breast fullness and nipple tenderness are common in breastfeeding mothers, especially in the early postpartum period. This discomfort alone does not indicate mastitis or any systemic infection.


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Related Questions

Correct Answer is A

Explanation

A. "I should visually monitor the client continuously when in mechanical restraints." Continuous visual monitoring is required to ensure the client’s safety, monitor for distress or injury, and assess the ongoing need for restraints. This is a key safety standard in the use of mechanical restraints.
B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." Skin integrity must be assessed much more frequently, typically every 15 to 30 minutes, to prevent injury or pressure-related complications while the client is restrained.
C. "I should expect the provider to evaluate the client within 4 hours of restraint application." For adults, a provider must evaluate the client within 1 hour of the initiation of mechanical restraints. A 4-hour delay does not meet safety or legal standards.
D. "I should ask the provider to write a prescription for mechanical restraints as needed." PRN (as-needed) prescriptions for restraints are not permitted. Each use must be justified, time-limited, and based on the client’s immediate behavior or condition.

Correct Answer is B

Explanation

A. Trim the fat from red meat prior to cooking. Children with cystic fibrosis often have difficulty absorbing fats due to pancreatic insufficiency, but they actually need higher fat intake to meet their increased energy demands. Trimming fat is not necessary or recommended.
B. Provide a diet high in protein and calories. Children with cystic fibrosis require a high-calorie, high-protein diet to support growth, maintain weight, and compensate for the energy lost due to chronic lung infections and malabsorption.
C. Administer pancreatic enzymes 30 min after meals. Pancreatic enzymes should be given before or with meals and snacks to aid digestion. Giving them 30 minutes after a meal reduces their effectiveness.
D. Give the child hot foods to reduce the sense of fullness. There is no evidence to support using hot foods to manage fullness in cystic fibrosis. Instead, meals should be nutrient-dense and timed to optimize digestion and absorption.

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