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 A
Explanation
Rationale:
A. "I know it will be a couple of weeks before the medication helps me feel better.": Tricyclic antidepressants like amitriptyline require 1–3 weeks to begin showing therapeutic effects. Understanding the delayed onset helps the client maintain adherence and avoid premature discontinuation due to perceived lack of efficacy.
B. "I can continue to take St. John's wort while taking this medication.": Combining amitriptyline with St. John’s wort can increase the risk of serotonin syndrome. Clients should avoid herbal supplements that may interact with antidepressants.
C. "I expect this medication to raise my blood pressure.": Amitriptyline more commonly causes orthostatic hypotension rather than hypertension. Clients should be aware of potential dizziness and fall risk associated with blood pressure drops.
D. "I should take this medication on an empty stomach": Incomplete statement, but typically, amitriptyline is taken at bedtime to minimize daytime sedation and anticholinergic side effects. Timing should be clarified to optimize safety and adherence.
Correct Answer is C
Explanation
A. A single light fixture along the sidewalk may not provide adequate lighting, increasing the risk of falls, and does not reflect proper home safety.
B. A small area rug at the front door can create a tripping hazard, indicating a need for improved safety measures.
C. Changing the batteries in the smoke alarms annually demonstrates that the client is maintaining functional smoke detectors, which is a key aspect of home safety. Regular maintenance of smoke alarms helps prevent fire-related injuries.
D. While a water heater set at 54° C (129.2° F) can prevent scalding, current safety recommendations suggest a slightly lower setting (around 49° C / 120° F) to maximize safety, so this is not the best indicator of proper understanding.
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