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 A
Explanation
Choice A rationale
Assessing for edema is an important action for the nurse to take when caring for a client who is 1 hr postpartum and has preeclampsia without severe features. Edema can be a sign of worsening preeclampsia.
Choice B rationale
Administering an IV bolus of lactated Ringer’s is not typically necessary for a client with preeclampsia without severe features.
Choice C rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to induce labor or treat postpartum hemorrhage, not preeclampsia.
Choice D rationale
Assisting the client with food intake is not directly related to the management of preeclampsia
Correct Answer is D
Explanation
Choice A rationale
Chorionic villus sampling (CVS) is a prenatal test that diagnoses chromosomal abnormalities such as Down syndrome, as well as a host of other genetic disorders. While it can determine the sex of the baby, it is not typically used for this purpose.
Choice B rationale
The statement that one cannot have an amniocentesis until they are at least 35 years of age is incorrect. While it is true that amniocentesis is often offered to women over the age of 35 due to an increased risk of chromosomal abnormalities, it can be performed on anyone at risk, regardless of age.
Choice C rationale
Scheduling the procedure for later in the day is not typically how amniocentesis is planned. It is a medical procedure that requires careful planning and preparation. It is usually performed between the 15th and 20th weeks of pregnancy.
Choice D rationale
This is the correct answer. Amniocentesis is a prenatal test that allows doctors to diagnose a range of genetic and chromosomal disorders. It involves taking a small sample of the amniotic fluid that surrounds the baby in the uterus for testing. The procedure can indeed determine if the baby has genetic or congenital disorders.
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