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 B
Explanation
Rationale:
A. A client who has an open compound fracture of the humerus: A compound fracture involves broken bone protruding through the skin and carries a risk of infection and significant blood loss. This client requires urgent care and should be tagged yellow (delayed) or red (immediate) depending on other injuries.
B. A client who has multiple facial lacerations: Facial lacerations that are not life-threatening can be treated after higher-acuity clients are stabilized. These clients are mobile, alert, and their injuries are minor, which qualifies them for a green tag (minimal, “walking wounded”).
C. A client who has a puncture wound in the right lower lung: A puncture wound to the lung can compromise respiratory function and oxygenation. This is a life-threatening injury, requiring immediate intervention and a red tag.
D. A client who has full-thickness burns over the lower extremities: Full-thickness burns compromise skin integrity and can lead to fluid loss, infection, and shock. This client needs urgent treatment and should be tagged red (immediate) or yellow (delayed) depending on the extent of burns and airway status.
Correct Answer is C
Explanation
Rationale:
A. "I need to be discharged now due to household responsibilities.": This statement reflects denial of the seriousness of preeclampsia and poor coping, as the client is prioritizing home duties over health. Clients with preeclampsia require rest, monitoring, and adherence to medical advice to prevent complications such as eclampsia or HELLP syndrome.
B. "I am so bored of being on restricted activity.": Expressing boredom is a normal emotional reaction but does not indicate effective coping. It shows frustration with activity limitations rather than acceptance and constructive adaptation to the treatment plan.
C. "I am using a notebook to record questions for my providers.": Keeping a notebook demonstrates proactive engagement and self-management. This behavior reflects effective coping, as the client is taking responsibility for understanding their condition and participating in care decisions to promote safety and adherence.
D. "I don't want any visitors while I'm here.": Avoiding social support may indicate withdrawal or emotional distress. Isolation can hinder coping and increase anxiety, whereas maintaining open communication and support networks usually improves adjustment to the condition.
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