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 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.
Correct Answer is C
Explanation
Choice A rationale
Breastfeeding at least six times per day is too infrequent for a newborn. Newborns typically need to feed more frequently, approximately 8-12 times in 24 hours, to establish a good milk supply and ensure adequate nutrition.
Choice B rationale
Keeping a baby on a strict breastfeeding schedule is not recommended. Feeding should be on demand, based on the baby's hunger cues, to promote effective breastfeeding and milk production.
Choice C rationale
Feeding the baby for 30 minutes during each feeding is correct. This duration allows adequate time for the baby to receive both foremilk and hindmilk, which is essential for nutrition and satiety.
Choice D rationale
Holding the baby just below the level of the breast is incorrect. The baby should be held at breast level to facilitate proper latch and comfortable feeding for both mother and baby. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.