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.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Bleeding gums can be common during pregnancy due to increased blood flow and hormonal changes that affect the gums, causing them to be more sensitive and prone to bleeding. It's usually not a cause for immediate concern unless it's severe or accompanied by other symptoms.

Choice B rationale

Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It's a significant symptom that needs immediate medical attention to ensure both maternal and fetal well-being.

Choice C rationale

White vaginal discharge, known as leukorrhea, is common during pregnancy due to increased production of estrogen and greater blood flow to the vaginal area. It helps prevent infections and usually does not indicate a problem unless it has a foul odor or is accompanied by itching or irritation.

Choice D rationale

Asymptomatic palpitations are relatively common during pregnancy due to increased blood volume and changes in circulation. They usually don't indicate a serious problem unless they're severe, persistent, or accompanied by other symptoms like chest pain or shortness of breath.

A. Increase the frequency of feedings from the affected nipple. B. Expose the affected nipple to the air between feedings. C. Apply vitamin E oil to the affected nipple before each feeding. D. Wash the affected nipple with soap and water before each feeding.

Correct Answer is B

Explanation

Choice A rationale

Increasing the frequency of feedings from the affected nipple may aggravate nipple soreness, as it doesn't allow the area to recover and heal properly between feedings.

Choice B rationale

Exposing the affected nipple to the air between feedings can help it to dry and heal, reducing soreness. Air exposure can help prevent bacterial growth and keep the nipple area healthy.

Choice C rationale

Applying vitamin E oil to the affected nipple before each feeding is not recommended as it can make the nipple slippery, affecting the baby's latch, and it might not be safe if ingested by the baby.

Choice D rationale

Washing the affected nipple with soap and water before each feeding can strip the natural oils from the skin, leading to further dryness and irritation, which can increase soreness.

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Correct Answer is B

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Correct Answer is B

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