A nurse on a postpartum unit is caring for a client.
The nurse should anticipate a provider's prescription for a(n)
The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}
Rationale for Correct Choices
- Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
- Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.
Rationale for Incorrect Choices
- Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
- Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
- Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. 42: A BMI of 42 falls in the category of class III (severe) obesity. This would only occur if the client's weight were significantly higher than 75 kg for a height of 1.8 m.
B. 28: A BMI of 28 indicates overweight status. At 75 kg and 1.8 m tall, the client does not meet the weight requirement for a BMI this high, as 28 would correspond to a weight closer to 91 kg.
C. 32: A BMI of 32 falls in the obesity range. For someone who is 1.8 m tall, a BMI of 32 would require a weight of about 104 kg, which is much higher than the client’s actual weight of 75 kg.
D. 24: The BMI is calculated as weight (kg) divided by height (m²). Using the formula:
BMI = 75 / (1.8 × 1.8) = 75 / 3.24 ≈ 23.15, which rounds to 24, placing the client in the normal weight range.
Correct Answer is A
Explanation
Rationale:
A. Measure the client's apical pulse while another nurse measures their radial pulse: Assessing for a pulse deficit involves comparing the apical and radial pulses simultaneously. A difference between the two indicates that not all heartbeats are reaching peripheral circulation, often seen in arrhythmias like atrial fibrillation.
B. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This method is used for measuring blood pressure, not for identifying pulse deficits. It does not provide information on the difference between central and peripheral pulse rates.
C. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This assesses for orthostatic changes, not pulse deficit. Pulse deficit requires comparison of apical and radial pulses, not positional changes in carotid pulse strength or rate.
D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing bilateral radial pulses helps detect differences in circulation or vessel obstruction but does not assess for a pulse deficit, which specifically involves apical-radial pulse comparison.
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