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)
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Determining the need for urinary catheterization is not a task that the nurse should assign to the PN, as this requires clinical judgment and critical thinking, which are beyond the scope of practice of the PN. This is a distractor choice.
Choice B: Titrating oxygen to prescribed parameters is a task that the nurse can assign to the PN, as this involves following orders and protocols, which are within the scope of practice of the PN. Therefore, this is the correct choice.
Choice C: Receiving a postoperative client and conducting the assessment is not a task that the nurse should assign to the PN, as this requires initial assessment and data collection, which are the responsibility of the registered nurse. This is another distractor choice.
Choice D: Evaluating and updating plans of care for clients is not a task that the nurse should assign to the PN, as this requires nursing diagnosis and outcome identification, which are part of the nursing process that only the registered nurse can perform. This is another distractor choice.
Correct Answer is ["A","D","E"]
Explanation
Choice A: Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a nursing action that the nurse can assign to the PN, as this is a basic skill that does not require complex judgment or intervention by the registered nurse. Therefore, this is a correct choice.
Choice B: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that the nurse should assign to the PN, as this is an advanced skill that requires close monitoring and evaluation by the registered nurse. This is an incorrect choice.
Choice C: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that the nurse should assign to the PN, as this involves administering controlled substances and assessing pain levels, which are beyond the scope of practice of the PN. This is another incorrect choice.
Choice D: Performing daily surgical dressing change for a client who had an abdominal hysterectomy is a nursing action that the nurse can assign to the PN, as this is a routine task that can be done under the supervision and direction of the registered nurse. Therefore, this is another correct choice.
Choice E: Administering a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM) is a nursing action that the nurse can assign to the PN, as this is an established protocol that can be followed by the PN with appropriate documentation and reporting. Therefore, this is another correct choice.
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