A nurse is assisting with the care of a client who gave birth 3 days ago.
Complete the diagram by dragging 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 []
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Uterine contractions lasting 30 to 45 seconds
Rationale: Uterine contractions lasting 30 to 45 seconds are within the expected range for the latent phase of labor. This duration indicates that contractions are occurring but are not too frequent or too prolonged, which is typical for this stage of labor.
B. Uterine contractions every 6 min
Rationale: Contractions every 6 minutes are also typical for the latent phase of labor, where contractions are still becoming more frequent as labor progresses. This frequency does not suggest fetal distress or a significant risk to the fetus.
C. Recurrent variable deceleration of the FHR
Rationale: Recurrent variable decelerations in fetal heart rate (FHR) indicate that the fetus might be experiencing umbilical cord compression. This finding suggests a risk to the fetus, as it can be associated with reduced oxygenation and may require intervention to manage labor and optimize fetal well-being.
D. Moderate variability of the FHR
Rationale: Moderate variability in FHR is an indication of a well-oxygenated fetus and a healthy autonomic nervous system. This is a reassuring sign of fetal well-being rather than a risk.
Correct Answer is D
Explanation
A. Petroleum jelly should be applied to prevent the diaper from sticking to the circumcision site, but it will not stop bleeding. Bright red blood oozing indicates that immediate action is needed to control bleeding.
B. Securing a clean diaper snugly could apply pressure but may not be the most effective method for controlling bleeding. It is more important to manage the bleeding directly by applying pressure.
C. Rinsing the newborn's penis with cool water is not an appropriate action for controlling bleeding. Cool water might be used for cleaning but does not address the issue of bleeding from the circumcision site.
D. Applying gentle pressure using a sterile dry gauze pad is the correct action to manage the bleeding. This method helps to control the bleeding by providing direct pressure to the site, which is crucial for addressing the issue.
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