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 D
Explanation
Rationale:
A. WBC count: A WBC of 13,000/mm³ is within the expected range for pregnancy, as mild leukocytosis commonly occurs due to physiologic changes, and does not require immediate reporting.
B. Fundal height: A fundal height of 27 cm at 29 weeks is slightly below average but may reflect individual variation, fetal position, or maternal factors. This finding warrants monitoring but is not an urgent concern.
C. Fetal heart rate: FHR of 158/min is within the normal range (110–160/min) for a fetus and does not indicate fetal distress, so immediate reporting is not necessary.
D. Hemoglobin: Hemoglobin of 10 g/dL is below the expected range for pregnancy (typically 11–16 g/dL). This indicates anemia, which can affect maternal and fetal oxygenation, making it important to report to the provider for further evaluation and management.
Correct Answer is D
Explanation
Rationale:
A. "Dehydration is caused by a decreased hemoglobin and hematocrit.": Dehydration typically results in increased, not decreased, hemoglobin and hematocrit values because fluid loss concentrates red blood cells. Low values would suggest anemia or blood loss rather than dehydration.
B. "Dehydration is associated with gastroesophageal reflux.": While dehydration may worsen nausea or fatigue, it is not directly linked to gastroesophageal reflux. GERD in pregnancy is usually caused by hormonal relaxation of the lower esophageal sphincter and increased intra-abdominal pressure from the enlarging uterus.
C. "Dehydration is treated with calcium supplements.": Calcium supplements are unrelated to treating dehydration. Management focuses on restoring fluid balance through oral or intravenous hydration to maintain uteroplacental perfusion and reduce uterine irritability.
D. "Dehydration can increase the risk for preterm labor.": Dehydration leads to increased secretion of antidiuretic hormone (ADH), which can stimulate oxytocin release and uterine contractions. Correcting dehydration helps reduce uterine activity and lowers the risk of preterm labor in pregnant clients.
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