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
Intramuscular injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice B rationale
Subcutaneous injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice C rationale
Intramuscular injection in the left vastus lateralis is the preferred route for administering phytonadione to a newborn. This muscle in the thigh is large enough to absorb the medication effectively.
Choice D rationale
Subcutaneous injection in the left vastus lateralis is not the preferred route for administering phytonadione to a newborn.
Correct Answer is C
Explanation
Correct answer: C. Poor feeding
Newborns exposed to methadone in utero are at risk for neonatal abstinence syndrome (NAS), which can manifest with:
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Poor feeding due to uncoordinated suck and swallow reflexes, irritability, and gastrointestinal symptoms.
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High-pitched cry, not weak—so option B is incorrect.
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Exaggerated Moro reflex, not absent—so option A is incorrect.
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Tachypnea (rapid breathing), often >60/min—so a respiratory rate of 30/min is abnormally low and not expected in this context, making option D incorrect.
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