The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

Moderate amount of foul-smelling lochia.

Blood pressure of 122/74 mm Hg

Oral temperature of 100.2°F (37.9°C..

White blood cell count of 19,000/mm^3 (19 x 10^9/L)

Answer and Explanation

The Correct Answer is A

Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.

Choice C reason: Oral temperature of 100.2°F (37.9°C. is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.

Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A is correct because the nurse's priority is to provide comfort and dignity to the dying patient. Pain management is an essential aspect of end-of-life care.

Choice B is incorrect because updating the nurse manager is not a priority action. The nurse manager can be informed later, after the patient's needs are met.

Choice C is incorrect because conveying the patient's status to the chaplain is not a priority action. The chaplain can be contacted later, after the patient's needs are met. The chaplain may also need the consent of the patient or the family before providing spiritual support.

Choice D is incorrect because documenting the impending signs of death is not a priority action. Documentation can be done later, after the patient's needs are met. Documentation is important, but not as important as providing comfort and dignity to the dying patient.

A. When the client has ankle edema. B. Within the first trimester of pregnancy. C. If the client has an elevated blood pressure. D. During admission to labor and delivery.

Correct Answer is C

Explanation

Choice A: When the client has ankle edema is not the most important time for the nurse to assess DTRs, as this is a common finding in pregnancy and does not indicate a neurological or vascular problem. This is a distractor choice.

Choice B: Within the first trimester of pregnancy is not the most important time for the nurse to assess DTRs, as this is a routine assessment that can be done at any time during pregnancy and does not reflect any specific risk or complication. This is another distractor choice.

Choice C: If the client has an elevated blood pressure is the most important time for the nurse to assess DTRs, as this can indicate preeclampsia, a serious condition that can cause seizures, stroke, and organ damage. DTRs can help detect hyperreflexia, which is a sign of increased intracranial pressure and impending eclampsia. Therefore, this is the correct choice.

Choice D: During admission to labor and delivery is not the most important time for the nurse to assess DTRs, as this is a standard assessment that can be done at any stage of labor and does not signify any urgent or emergent situation. This is another distractor choice.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A dietitian with a prescription for no not resuscitate (DNR) begins to manifest signs of impending death. After notifying the family of the patient's status, what priority action should the nurse implement?

Correct Answer is A

Explanation

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is C

Explanation

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. Theclient is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)