The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:
Document expected postpartum mucous membrane congestion
Notify the charge nurse of a possible upper respiratory infection
Notify the physician of a possible pulmonary embolism
Medicate with antipyretic remedy for elevated temperature
The Correct Answer is C
Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.
Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.
Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.
Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Prevent infection of the eyes from vaginal bacteria. This is because some newborns can be exposed to bacteria such as gonorrhea or chlamydia during delivery, which can cause a serious eye infection called gonococcal ophthalmia neonatorum (GON). Applying an antibiotic ointment such as erythromycin or ilotycin can prevent GON and other less severe eye infections by killing the bacteria.
Choice A is not correct because the umbilical cord does not need antibiotic ointment to prevent infection. It should be kept clean and dry until it falls off naturally.
Choice C is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes that drain tears from the eyes to the nose.
Choice D is not correct because the urethra is not a common site of infection for newborns. The urethra is the tube that carries urine from the bladder to the outside of the body.
Correct Answer is D
Explanation
Determine the client’s temperature. This is because shaking chills during the immediate postpartum period can be a sign of infection, such as endometritis or mastitis. Infection is a serious complication that can lead to sepsis and shock if not treated promptly. The nurse should measure the client’s temperature and look for other signs of infection, such as foul-smelling lochia, breast tenderness, or tachycardia.
Choice A is wrong because placing the client on seizure precautions is not indicated for shaking chills. Seizure precautions are used for clients who have eclampsia or other conditions that increase the risk of seizures.
Choice B is wrong because covering the client with warm blankets may not be helpful for shaking chills. Warm blankets may increase the body temperature and worsen the infection.
Choice C is wrong because notifying the charge nurse is not the first action the nurse should take. The nurse should assess the client’s condition before reporting to the charge nurse or the provider.
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