A nurse is assisting with the care of a 28-year-old female client who gave birth 3 days ago in the maternal newborn unit.
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Endometritis is indicated by a high temperature (38.4°C), elevated heart rate (108/min), foul-smelling lochia, and a tender boggy uterus. These are classic signs of infection post-cesarean birth, particularly following prolonged rupture of membranes, which increases infection risk. Administering broad-spectrum antibiotics targets the infection, while oxytocic medication helps manage uterine atony and promote uterine contraction to expel infected lochia.
Actions Explanation:
- Administer broad-spectrum antibiotic medication: This addresses the underlying infection causing endometritis.
- Monitor the administration of an oxytocic medication: Ensures uterine contraction, reducing uterine atony and helping clear infected materials.
Parameters to Monitor:
- Temperature: Indicates the presence and resolution of infection.
- Lochia amount and odor: Helps assess the severity of infection and effectiveness of treatment.
Other Conditions:
- B. Urinary tract infection (UTI): Less likely since the client denies urinary symptoms like burning or difficulty.
- C. Deep vein thrombosis (DVT): Bilateral lower extremity edema without pain, warmth, or tenderness doesn't align with unilateral swelling/pain typical of DVT.
- D. Engorgement: Not likely since the client is bottle-feeding and denies nipple discomfort; also, the lochia characteristics and boggy uterus point to infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Chemotherapy is not a standard treatment for a molar pregnancy unless malignancy is suspected or confirmed. It is usually monitored with regular HCG levels and follow-up.
Choice B rationale
Attending a support group is crucial for emotional support and ensuring that the client has access to resources and information about recovery and future pregnancy planning.
Choice C rationale
Home palliative services are not typically required after a molar pregnancy unless there are specific complications that necessitate such care. The focus is generally on monitoring HCG levels and follow-up.
Choice D rationale
An amniocentesis is not needed after a molar pregnancy. Follow-up includes HCG level monitoring to ensure all molar tissue is gone and to watch for malignancy, not amniocentesis.
Correct Answer is C
Explanation
Choice A rationale
History of methicillin-resistant Staphylococcus aureus (MRSA) is not directly related to the use of a cervical cap. The main concern with a cervical cap is infection, but MRSA history alone doesn't make it a contraindication for this form of contraception.
Choice B rationale
History of thrombophlebitis is more of a concern with hormonal contraceptives due to the risk of blood clots. A cervical cap does not involve hormones, so this condition is not a direct contraindication.
Choice C rationale
History of toxic shock syndrome (TSS) is a contraindication for the use of a cervical cap because the cap can increase the risk of developing TSS again. TSS is associated with prolonged use of barrier contraceptives, which can create an environment that fosters the growth of bacteria responsible for TSS.
Choice D rationale
Type 1 diabetes mellitus is not a direct contraindication for the use of a cervical cap. The concern with diabetes is often related to blood glucose control and potential infections, but it doesn't specifically contraindicate the use of cervical caps.
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