A nurse is caring for a female client, age 36, in the postpartum unit following a scheduled cesarean birth 12 hours ago.

Complete the following sentence by using the lists of options.
The client is at greatest risk for developing

as evidenced by the client’s

.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

The client is at greatest risk for developing Endometritis as evidenced by the client’s Lochia characteristics.

Rationale for correct answers:
Endometritis is a postpartum uterine infection commonly occurring after cesarean birth due to ascending bacterial contamination. The client’s foul-smelling lochia is a hallmark sign, indicating infection of the uterine lining. Normally, lochia is odorless and changes from red to serous and then to white over weeks postpartum. The elevated WBC count (18,000/mm³; normal 5,000–15,000/mm³) supports infection but is nonspecific. The firm uterine tone reduces likelihood of postpartum hemorrhage. Urinalysis positive for bacteria suggests UTI but does not explain uterine signs. Hence, lochia changes are the most direct indicator of endometritis.

Rationale for incorrect Response 1 answers:
Postpartum hemorrhage typically involves heavy bleeding, uterine atony, or a rapidly dropping hematocrit, none of which is reported here. Urinary tract infection is suggested by urinalysis but does not account for uterine tenderness or foul lochia. Deep vein thrombosis would present with limb swelling, pain, and possible fever but no uterine or lochia changes.

Rationale for incorrect Response 2 answers:
Urinalysis positive for bacteria points to UTI but not uterine infection. Elevated WBC count indicates infection or inflammation but lacks specificity for endometritis versus other infections. Uterine tone is firm here, making hemorrhage or uterine atony unlikely and less relevant to infection diagnosis.

Take home points:

Endometritis often presents postpartum with foul-smelling lochia and elevated WBC.
Foul-smelling lochia is a critical clinical sign distinguishing endometritis from other postpartum complications.
Positive urinalysis suggests UTI, a separate postpartum infection that requires differentiation.
Uterine tone helps rule out hemorrhage and guides diagnosis of infection versus atony.

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Correct Answer is C

Explanation

Choice A rationale

Meconium aspiration syndrome is primarily associated with post-term gestation or fetal distress, where the fetus passes meconium in utero and subsequently aspirates it. While fetal distress can occur with PPROM, it is not the *most* direct or primary complication anticipated in the newborn due to preterm premature rupture of membranes itself.

Choice B rationale

Polycythemia, an abnormally high red blood cell count, is not a direct complication expected in a newborn specifically due to preterm premature rupture of membranes. It is more commonly associated with chronic hypoxia, maternal diabetes, or certain genetic conditions, and not a direct consequence of prolonged membrane rupture.

Choice C rationale

Sepsis is a significant and highly anticipated complication in a newborn following preterm premature rupture of the membranes (PPROM). The prolonged absence of the amniotic sac, which normally acts as a protective barrier, increases the risk of ascending infection from the maternal genital tract to the fetus, leading to neonatal sepsis.

Choice D rationale

Hyperbilirubinemia, or jaundice, is common in newborns, especially preterm infants, due to immature liver function. However, it is not a specific complication directly and primarily caused by preterm premature rupture of membranes. While prematurity itself is a risk factor for hyperbilirubinemia, PPROM does not directly induce elevated bilirubin levels. .

A. Administer magnesium sulfate bolus B. Insert an indwelling urinary catheter C. Initiate intravenous (IV) fluids D. Administer nifedipine 30 mg intermittent IV bolus E. Begin intermittent electronic fetal monitoring

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Administer magnesium sulfate bolus: Anticipated. Magnesium sulfate is the drug of choice to prevent seizures in severe preeclampsia or eclampsia. The client shows signs of severe preeclampsia (hypertension, headache, visual disturbances, hyperreflexia, clonus, epigastric pain), so a magnesium sulfate bolus is appropriate to reduce CNS irritability and prevent eclamptic seizures.
Insert an indwelling urinary catheter: Anticipated. Monitoring urine output is essential in hypertensive disorders of pregnancy to assess kidney function and fluid balance. The client’s urine output (25–55 mL/hr) is borderline low (normal >30 mL/hr), so catheter insertion allows accurate measurement.
Initiate intravenous (IV) fluids: Contraindicated. In preeclampsia, patients often have intravascular volume depletion with risk of pulmonary edema due to increased capillary permeability. IV fluids should be carefully restricted to avoid fluid overload, so routine IV fluid initiation is contraindicated unless hypovolemia or dehydration is confirmed.
Administer nifedipine 30 mg intermittent IV bolus: Contraindicated. Nifedipine, a calcium channel blocker, is given orally for hypertension in pregnancy, but intermittent IV bolus administration is not recommended because it can cause abrupt hypotension and fetal distress.
Begin intermittent electronic fetal monitoring: Anticipated. Continuous or intermittent fetal monitoring is critical for detecting fetal distress, especially in high-risk pregnancies with maternal hypertension and irregular contractions, ensuring timely intervention if needed.

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A nurse is caring for a female client, age 36, in the postpartum unit following a scheduled cesarean birth 12 hours ago. Complete the following sentence by using the lists of options. The client is at greatest risk for developing __________ as evidenced by the client’s __________.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 35 weeks of gestation and has preterm premature rupture of the membranes. Which of the following complications should the nurse monitor the newborn for following delivery?

Correct Answer is C

Explanation

A nurse is caring for a female client, age 30, at 37 weeks of gestation in the labor and delivery unit for blood pressure observation. For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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A nurse is caring for a female client, age 36, in the postpartum unit following a scheduled cesarean birth 12 hours ago.

Complete the following sentence by using the lists of options.
The client is at greatest risk for developing

as evidenced by the client’s

.