A nurse is assisting with the care of a postpartum 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 evaluate the client's progress.
The Correct Answer is []
- Endometritis. The client has fever (38.4°C/101.1°F), tachycardia (HR 108/min), uterine tenderness, and foul-smelling lochia, all of which indicate postpartum uterine infection. Prolonged rupture of membranes and cesarean birth increase the risk of endometritis.
- Engorgement. The client reports firm and heavy breasts but denies nipple discomfort, making engorgement unlikely as the primary issue.
- Deep vein thrombosis. The client has bilateral lower extremity edema but no pain, warmth, or tenderness, which are key signs of DVT.
- Urinary tract infection. The client reports frequent voiding without difficulty, with no dysuria or suprapubic pain, making a UTI unlikely.
- Plan to administer broad-spectrum antibiotic medication. Endometritis is a bacterial infection requiring IV broad-spectrum antibiotics, such as clindamycin and gentamicin, to prevent further complications.
- Administer an oxytocic medication. Oxytocic agents like oxytocin or methylergonovine help contract the uterus, promoting lochia drainage and reducing bacterial growth, which helps resolve infection.
- Apply ice packs to the breasts. This is used to relieve breast engorgement, but the primary concern is infection, not breast discomfort.
- Encourage the client to increase fluid intake. Hydration is important but does not directly treat endometritis, making it a lower priority.
- Initiate anticoagulant therapy. This is necessary for DVT management, but the client does not have symptoms of a clotting disorder.
- Temperature. Fever is a key sign of infection, and monitoring temperature helps assess the effectiveness of antibiotic therapy.
- Lochia amount and odor. Foul-smelling lochia is a major sign of endometritis, and monitoring for changes in amount or color helps evaluate treatment progress.
- Bladder distension. The client is voiding frequently without difficulty, making bladder monitoring unnecessary.
- Integrity of the nipples. This is only relevant for breastfeeding clients, and the client is bottle-feeding, making it not applicable.
- Circumference of lower extremities. This is monitored for DVT progression, which is not suspected in this client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You should feed your baby six times a day." Newborns typically need to breastfeed 8 to 12 times per day, about every 2 to 3 hours, to ensure adequate nutrition and growth. Feeding only six times per day may not provide enough milk intake, increasing the risk of dehydration and poor weight gain.
B. "You should wake your baby at least every 6 hours at night for feedings." Newborns should be woken for feedings at least every 3 to 4 hours if they do not wake on their own, especially in the first few weeks. Longer intervals between feedings can lead to inadequate nutrition, dehydration, and poor weight gain.
C. "You should recognize that your baby sucking on his hands is a hunger cue." Early hunger cues include rooting, sucking on hands, smacking lips, and increased alertness. Crying is a late hunger cue, meaning the baby may already be overly hungry and difficult to calm for feeding. Recognizing early hunger cues helps ensure a smooth and effective feeding process.
D. "You should feed your baby for 10 minutes on each breast." The length of time a baby feeds on each breast varies. It is important to allow the baby to feed for as long as needed to ensure they receive both foremilk (watery milk for hydration) and hindmilk (higher-fat milk for satiety and growth). Strict time limits can lead to inadequate milk transfer and poor weight gain.
Correct Answer is A
Explanation
A. "I’ll take a sitz bath to relieve my discomfort." A sitz bath can help soothe itching, irritation, and inflammation caused by vaginal candidiasis. Warm water provides relief without disrupting the vaginal flora or interfering with treatment. Sitz baths should be used in addition to antifungal therapy, not as a replacement.
B. "I can stop using the cream while I have my period." Miconazole vaginal cream should be used for the full prescribed duration, even during menstruation. Stopping treatment early increases the risk of recurrence. If using applicators, the client may prefer to use sanitary pads instead of tampons to avoid interference with medication absorption.
C. "I can stop using the cream when the discharge stops." Vaginal candidiasis treatment should continue for the full course, even if symptoms improve before completion. Stopping early can lead to an incomplete cure and increase the risk of recurrent infections. Clients should follow the recommended duration of therapy, typically 3 to 7 days, depending on the product.
D. "I’ll use a douche every day until the discharge stops." Douching is not recommended as it can disrupt the natural vaginal flora, worsen irritation, and potentially prolong the infection. Instead, clients should maintain good hygiene by washing the external genital area with mild soap and water while continuing antifungal treatment.
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