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. Fever is not a common adverse effect of epidural anesthesia. Fever is more commonly associated with infection or other causes and would require further investigation but is not directly linked to the epidural itself.
B. Tachypnea is not an expected adverse effect of epidural anesthesia. It may be a sign of anxiety, pain, or respiratory complications, but it is not typically caused by the epidural.
C. Tachycardia can be an adverse effect of epidural anesthesia. It may occur as a compensatory mechanism due to hypotension, which is a known side effect of epidural anesthesia. When blood pressure drops, the heart rate may increase to maintain cardiac output.
D. Hypertension is generally not associated with epidural anesthesia. Hypotension is more common due to the vasodilatory effects caused by sympathetic nerve blockade, rather than an increase in blood pressure.
Correct Answer is A
Explanation
A. Witch hazel pads can soothe the perineal area and reduce discomfort from an episiotomy and hemorrhoids. This is a common and effective part of postpartum perineal care.
B. Heat packs are not recommended for episiotomy care as they can increase swelling. Instead, cold packs or ice can be used to reduce swelling and discomfort.
C. Numbing sprays should not be used prior to cleansing the area. Instead, gentle cleaning with mild soap and water is recommended for postpartum perineal care.
D. A sitz bath should typically be used for 15 to 20 minutes, not just 10 minutes, to effectively soothe the perineal area and promote healing.
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