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 C
Explanation
Choice A rationale
Instructing the client to avoid urinary elimination until after administration is not necessary. The administration of dinoprostone does not interfere with the client’s ability to urinate.
Therefore, this action is not required.
Choice B rationale
Placing the client in a semi-Fowler’s position for 1 hr after administration is not a necessary action. While positioning can be important in certain medical procedures, there is no specific requirement for a semi-Fowler’s position in the administration of dinoprostone.
Choice C rationale
Verifying that informed consent is obtained prior to administration is a crucial step in any medical procedure, including the administration of dinoprostone. Informed consent ensures that the client is aware of the procedure, its purpose, and any potential risks or benefits. It is a legal and ethical requirement.
Choice D rationale
Allowing the medication to reach room temperature prior to administration is not a necessary action. There is no specific requirement for dinoprostone to be at room temperature before administration.
Correct Answer is B
Explanation
Choice A rationale
The influenza vaccine is recommended for all pregnant women, but it is not the only vaccine that should be administered to a pregnant woman who has received no immunizations during childhood.
Choice B rationale
The Tetanus, Diphtheria, Pertussis (Tdap) vaccine is recommended for all pregnant women, regardless of their prior immunization status. This vaccine protects against three serious diseases caused by bacteria. The antibodies that the pregnant woman’s body makes in response to the vaccine are passed on to the baby through the placenta, providing the baby with short-term protection against these diseases until they can receive their own vaccines.
Choice C rationale
The Hepatitis B vaccine is not typically given during pregnancy unless the woman is at risk for Hepatitis B infection.
Choice D rationale
The Pneumococcal vaccine is not typically given during pregnancy unless the woman has certain health conditions that increase her risk for pneumococcal disease
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