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. The deltoid muscle is not recommended for newborns; the vastus lateralis is the preferred site for intramuscular injections.
B. A 25-gauge needle is an appropriate size for newborn injections, but needle choice alone is not the priority action for this specific medication administration.
C. Phytonadione (Vitamin K) is typically administered within the first 6 to 12 hours after birth, allowing time for initial stabilization and bonding before injection, while still preventing vitamin K deficiency bleeding.
D. The mother’s Rh factor is unrelated to vitamin K administration; it is only assessed when considering the need for Rho(D) immune globulin.
Correct Answer is C,E,A,B,D
Explanation
1. Wrap a warm, moist cloth around the heel to dilate the blood vessels, which makes it easier to obtain the blood sample.
2. Cleanse the heel with an antiseptic to reduce the risk of infection at the puncture site.
3. Puncture the heel and collect the blood, ensuring that the sample is adequate for the test.
4. Apply pressure with a dry gauze pad to stop the bleeding from the puncture site.
5. Cover the heel with an adhesive bandage to protect the area and minimize the risk of infection.
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