A nurse is caring for a female client who gave birth 3 days ago in the postpartum unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct condition Endometritis is a postpartum uterine infection, common after cesarean birth and prolonged rupture of membranes. The client presents with fever >38°C, uterine tenderness, and foul-smelling lochia, hallmark signs of endometritis. A boggy uterus indicates subinvolution due to infection. Malaise and chills reflect systemic inflammatory response. Bottle-feeding excludes mastitis or engorgement as primary cause.
Rationale for correct actions Broad-spectrum antibiotics like clindamycin and gentamicin target polymicrobial flora including group B streptococci and anaerobes. Prompt administration reduces risk of sepsis and uterine abscess. Oxytocic agents like oxytocin promote uterine contraction, aiding involution and expulsion of infected lochia. This reduces bacterial load and improves antibiotic penetration.
Rationale for correct parameters Temperature monitoring detects systemic infection progression; normal postpartum range is <38°C. Persistent elevation suggests inadequate response to therapy. Lochia assessment identifies changes in volume and odor; normal lochia rubra transitions to serosa by day 3–4. Foul odor and dark color indicate retained infected tissue.
Rationale for incorrect conditions Deep vein thrombosis presents with unilateral leg pain, warmth, and swelling, absent here. Urinary tract infection causes dysuria, urgency, and suprapubic pain, not present. Engorgement causes bilateral breast fullness and discomfort, but client is bottle-feeding and denies nipple pain.
Rationale for incorrect actions Anticoagulant therapy is irrelevant without thrombotic signs. Fluid intake helps urinary tract infections, not uterine infections. Ice packs treat breast engorgement, not uterine infection.
Rationale for incorrect parameters Nipple integrity relates to breastfeeding complications. Bladder distention is not present and unrelated to uterine infection. Leg circumference monitors DVT, not endometritis.
Take home points:
- Endometritis is a postpartum uterine infection marked by fever, uterine tenderness, and foul lochia.
- Cesarean delivery and prolonged rupture of membranes are major risk factors.
- Management includes antibiotics and uterine contraction support.
- Differentiate from DVT, UTI, and engorgement using targeted signs and history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Choice A rationale: Weight is a crucial anthropometric measurement for evaluating a newborn's physical development, nutritional status, and overall health. It is typically recorded in grams or kilograms immediately after birth and monitored regularly. Normal birth weight is generally between 2,500 grams (5 lbs 8 oz) and 4,000 grams (8 lbs 13 oz). Deviations from this range, such as low birth weight, necessitate closer monitoring and specialized care.
Choice B rationale: The type of birth, whether vaginal, operative vaginal (e.g., forceps or vacuum assisted), or cesarean section, is a vital piece of obstetric history. This information is critical as it highlights potential risks the neonate may have encountered, such as transient tachypnea of the newborn following a C-section or trauma associated with a complicated vaginal delivery, and informs future care decisions.
Choice C rationale: The Apgar scores are a rapid, standardized assessment of five physiologic signs (Appearance, Pulse, Grimace, Activity, Respiration) used to evaluate a newborn's transition to extrauterine life. Scores are recorded at one and five minutes after birth. A score between 7 and 10 is considered normal and reassuring, while lower scores indicate the need for immediate intervention and closer observation.
Choice D rationale: Gestational age, typically determined by the last menstrual period and validated by a physical assessment (e.g., Ballard Scale), is essential for classifying the neonate as preterm, full-term, or post-term. It directly correlates with the maturity of organ systems, including the lungs and brain, and dictates the expected range of normal findings and potential risk for specific complications like hyperbilirubinemia or respiratory distress syndrome.
Choice E rationale: The heart rate is a fundamental vital sign, reflecting cardiovascular stability and is a key component of the Apgar score. Normal range for a newborn is typically 110 to 160 beats per minute. A sustained heart rate outside this range, either bradycardia or tachycardia, can signal distress, hypoxia, infection, or other underlying pathology, requiring immediate clinical investigation and intervention.
Choice F rationale: Length (or Crown-Heel length) is an important anthropometric measure recorded alongside weight and head circumference. It helps assess the newborn's growth potential and identify potential intrauterine growth restriction or genetic syndromes when plotted on standardized growth charts. Normal full-term length is generally between 45 and 55 centimeters (17.7 to 21.7 inches).
Correct Answer is B
Explanation
Choice A rationale
The proper sequence for suctioning a newborn is the mouth first, then the nose, to prevent the newborn from aspirating secretions. Suctioning the nose first may cause the newborn to gasp, drawing pharyngeal secretions into the trachea and lungs, potentially leading to aspiration pneumonia or respiratory distress.
Choice B rationale
Depressing the bulb prior to insertion into the mouth or nose creates a negative pressure inside the bulb. Releasing the pressure after insertion will then effectively draw secretions into the bulb, achieving optimal suction. Inserting a non-depressed bulb will be ineffective for removing secretions.
Choice C rationale
The bulb syringe does not require lubrication with sterile water before use; it is intended for immediate use as a mechanical suction device. Lubrication could potentially introduce excess fluid into the newborn's airway or dilute secretions, which does not enhance the device's primary function of removing mucus.
Choice D rationale
The bulb should be placed gently into the sides of the newborn's mouth, rather than the center, to avoid stimulating the gag reflex. Placing it at the sides directs suction toward the cheeks and gums, facilitating the removal of secretions from the oral cavity without causing discomfort or vomiting.
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