A nurse onapostpartum unit is caring for a client.
Kleihauer-Betke test
Tocolytic medication
Intravenous antibiotic
increase in daily fluid intake
intrauterine tamponade balloon
Correct Answer : C,D
Rationale for Correct Choices
• Intravenous antibiotic: The client shows classic signs of postpartum endometritis, including fever, uterine tenderness, boggy fundus, and foul-smelling lochia. IV antibiotics are the primary treatment to target the uterine infection and prevent progression or sepsis.
• Increase in daily fluid intake: Adequate hydration supports circulation, helps maintain uterine tone, and assists in reducing the risk of complications such as hypotension or dehydration from infection. Fluids also support antibiotic therapy by promoting renal clearance and overall recovery.
Rationale for Incorrect Choices
• Kleihauer-Betke test: This test identifies fetal-to-maternal hemorrhage, which is not indicated here because the client’s hemoglobin is stable and there is no evidence of significant postpartum hemorrhage.
• Tocolytic medication: Tocolytics are used to suppress preterm labor, which is irrelevant for this postpartum client whose uterus has already delivered the fetus.
• Intrauterine tamponade balloon: This intervention is used for severe postpartum hemorrhage to mechanically control bleeding. The client’s bleeding is moderate and the uterus is firm after massage, so this is not indicated at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.
B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.
C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.
D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.
Correct Answer is C
Explanation
Rationale:
A. Tends to be very expressive with gestures and body language: Chinese cultural norms often value modesty and restrained expression rather than overt gestures. Expecting expressive behavior may not align with typical postpartum practices.
B. Prefers to make direct eye contact with health care personnel: In many Chinese cultural contexts, avoiding direct eye contact is a sign of respect, especially toward authority figures, rather than a preference for direct engagement.
C. Prefers foods that maintain a balance of hot and cold within the body: Traditional Chinese postpartum practices emphasize restoring balance through diet, often using “hot” and “cold” foods to support recovery and prevent illness, making this a key consideration in care planning.
D. Expresses pain freely and loudly: Cultural norms often encourage quiet endurance of pain, especially postpartum, rather than vocal or exaggerated expressions of discomfort.
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