A nurse is caring for a 28-year-old female client in the postpartum unit who gave birth 3 days ago. The client had a cesarean birth following prolonged rupture of membranes and cephalopelvic disproportion. The client reports general malaise, chills, and a decreased appetite.
The Correct Answer is []
• Endometritis: The client’s symptoms such as general malaise, chills, decreased appetite, elevated temperature, boggy and tender uterus, and foul-smelling lochia suggest that she is most likely experiencing endometritis, an inflammation of the inner lining of the uterus, typically due to infection.
• Actions to take: The nurse should administer the prescribed IV antibiotics to treat the infection. The nurse should also encourage fluid intake to help flush out the bacteria from the body and prevent dehydration.
• Parameters to monitor: The nurse should monitor the client’s temperature to assess for fever, which can be a sign of infection. The nurse should also monitor the amount and odor of the client’s lochia, as changes can indicate worsening infection. If the client’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Preparing the client to receive a plasma expander is not the first action the nurse should take. While it may be necessary in severe cases of hemorrhage, the first action should be to ensure the client’s oxygenation.
Choice B rationale
Administering oxygen via face mask at 10 L/min is the first action the nurse should take. This is because a client who is saturating perineal pads every 10 to 15 minutes is likely experiencing a significant blood loss, which can lead to hypoxia.
Choice C rationale
Inserting an indwelling urinary catheter may be necessary in some cases, but it is not the first action the nurse should take.
Choice D rationale
Collecting hemoglobin and hematocrit levels is important to assess the extent of blood loss, but it is not the first action the nurse should take.
Correct Answer is C
Explanation
Choice A rationale
While magnesium sulfate can have an effect on the fetal heart rate, it does not primarily function to stabilize it. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties.
Choice B rationale
Magnesium sulfate does not primarily function to improve tissue perfusion. Its main role in the management of preeclampsia is to prevent seizures.
Choice C rationale
This is the correct answer. Magnesium sulfate is used in the management of preeclampsia primarily due to its anticonvulsant properties. It helps to prevent seizures in those with severe preeclampsia, which can minimize the risk of complications.
Choice D rationale
Magnesium sulfate does not increase cardiac output. Its primary role in the management of preeclampsia is to prevent seizures.
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