The nurse is collecting data from the client 24 hr later.
How should the nurse interpret the findings?
Moderate lochia rubra: Sign of potential improvement.
Client reports decreased level of pain: Sign of potential improvement.
Temperature 38.4°C (101°F): Sign of potential worsening condition.
WBC count 15,000/mm³ : Sign of potential worsening condition.
The Correct Answer is C
Choice A rationale
Moderate lochia rubra is normal postpartum bleeding and does not indicate a worsening condition.
Choice B rationale
Decreased pain suggests recovery rather than deterioration.
Choice C rationale
A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.
Choice D rationale
An elevated WBC count indicates an immune response, which may suggest infection or inflammation, pointing to a worsening condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Explanation
Given the client's condition, the nurse should anticipate a provider's prescription for continuous fetal monitoring due to the client’s term gestation with regular contractions. This ensures close observation of both the fetal heart rate and the progress of labor, as the client is at full term with consistent contractions.
Correct Answer is A
Explanation
Choice A rationale
Encouraging ambulation as often as possible helps to stimulate circulation and prevent the formation of blood clots in the legs, thereby reducing the risk of thrombophlebitis. Movement promotes venous return and prevents stasis, which is a primary factor in clot formation.
Choice B rationale
Warm, moist packs can provide comfort and relieve muscle tension but are not specifically effective in preventing thrombophlebitis. They do not promote circulation as effectively as ambulation.
Choice C rationale
Elastic stockings can be helpful in maintaining venous return but should be used alongside other measures like ambulation. They alone are insufficient to prevent thrombophlebitis if the client remains immobile.
Choice D rationale
NSAIDs can reduce inflammation and pain but do not specifically prevent thrombophlebitis. Regular movement and other preventive measures are necessary to effectively prevent blood clots.
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