A nurse is assisting with the care of a client who gave birth 3 days ago.

Exhibits

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.

Answer and Explanation

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

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Correct Answer is A

Explanation

A. The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity. A higher ratio indicates that the baby's lungs are mature enough to handle breathing air outside the womb, which is the primary purpose of this test.
B. The L/S ratio test does not assess placental function. Placental function is evaluated through other tests, such as Doppler studies or biophysical profiles.
C. The L/S ratio test is not related to Rh incompatibility. Rh incompatibility issues are managed through different assessments, such as the Coombs test and Rh factor screening.
D. The L/S ratio test does not indicate genetic disorders. Genetic disorders are assessed through tests like amniocentesis or chorionic villus sampling, not the L/S ratio.

A. Use a lancet to puncture the inner aspect of the newborn's heel. B. Warm the newborn's heel for 5 to 10 min before the puncture. C. Apply an antiseptic to the newborn's heel after collecting the specimen. D. Leave the newborn's heel open to the air after the puncture.

Correct Answer is B

Explanation

A. The lancet should be used on the outer aspect of the heel, not the inner aspect, to avoid injury to the heel's bone and nerves. Proper technique for heel puncture is critical for successful specimen collection.
B. Warming the newborn’s heel for 5 to 10 minutes before the puncture helps to increase blood flow and ensure a sufficient blood sample for screening tests. This is a recommended practice to improve the effectiveness of the heel stick.
C. Applying an antiseptic to the heel before the puncture is correct practice, but applying it after the specimen is collected is not recommended. It can cause stinging and potentially interfere with the blood sample.
D. After the puncture, the heel should be gently massaged and then covered with a bandage to stop bleeding. Leaving the heel open to the air is not recommended as it can lead to infection or continue bleeding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is undergoing amniotic fluid assessment for the lecithin/sphingomyelin ratio. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to collect a specimen for newborn screening. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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