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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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
Correct Answer is D
Explanation
Choice A rationale
Checking the newborn’s identification using the crib card is not the most reliable method. The crib card could be misplaced or switched accidentally.
Choice B rationale
Requiring visitors to wear an identification band does not directly ensure the proper identification of newborns. While it can enhance the security of the unit, it does not link the newborn to their correct parents.
Choice C rationale
Replacing the infant’s identification band after his name has been recorded is not the most effective method. The identification band should be placed on the newborn immediately after birth to prevent mix-ups.
Choice D rationale
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is the correct answer. This method is a reliable way to identify newborns. The footprints, along with the mother’s fingerprints, are often taken within the first hour after birth. This can be used for identification throughout the hospital stay.
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