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 []
Explanation
- Potential Condition: Hyperemesis Gravidarum
Actions to take
- Insert a peripheral venous access device:
- Monitor and manage electrolyte values:
Parameters to monitor
- Electrolyte values:
- Urine ketones:
Rationale
- Potential Condition: Hyperemesis Gravidarum
- This condition is characterized by severe nausea and vomiting, leading to dehydration and nutrient loss, which can affect both the mother and fetus.
- Actions to Take:
1. Insert a peripheral venous access device:
- This will allow for the administration of IV fluids and medications to treat dehydration and correct electrolyte imbalances.
2. Monitor and manage electrolyte values:
- Given the client's low potassium levels, it's crucial to monitor and manage electrolytes to prevent complications.
- Parameters to Monitor:
1. Electrolyte values:
- Monitoring electrolyte levels is essential to ensure they are within normal ranges and to adjust IV fluid composition as needed.
2. Urine ketones:
- Positive urine ketones indicate that the body is using fat for energy due to inadequate glucose utilization, which is common in Hyperemesis Gravidarum. Monitoring will help assess the effectiveness of treatment and nutritional status.
Correct Answer is B
Explanation
A. Magnesium sulfate is used to manage preeclampsia or prevent preterm labor, not for treating an ectopic pregnancy. It does not address the issue of an unruptured ectopic pregnancy.
B. Methotrexate is a medication used to treat an unruptured ectopic pregnancy by dissolving the ectopic tissue and allowing it to be reabsorbed by the body. It is a first-line treatment for early, unruptured ectopic pregnancies to prevent complications.
C. Calcium gluconate is used to treat hypocalcemia or to counteract the effects of magnesium sulfate in preeclampsia, not for ectopic pregnancies. It is not relevant to the management of an unruptured ectopic pregnancy.
D. Terbutaline is used to manage preterm labor by relaxing uterine contractions. It does not address the treatment of an ectopic pregnancy and is not indicated for this condition.
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