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.

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Correct Answer is A

Explanation

Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.

Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.

Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.

Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.

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

Correct Answer is B

Explanation

Choice B is correct because assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.

Choice A is incorrect because ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.

Choice C is incorrect because assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.

Choice D is incorrect because assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.

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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

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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)