A nurse is caring for a postpartum female client who gave birth 3 days ago in a hospital setting.
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 evaluate the client’s progress.
The Correct Answer is []
Based on the provided information, here’s the completed diagram:
Potential Condition
- D. Endometritis
Actions to Take
- A. Administer broad-spectrum antibiotics
- D. Administer analgesics
Parameters to Monitor
- A. Lochia amount and odor
- B. Temperature
Explanation of Other Conditions
- Deep vein thrombosis (DVT):
- Reasoning: The client has bilateral edema without pain, warmth, or tenderness, which are typical signs of DVT. Additionally, the primary symptoms (malaise, chills, fever, foul-smelling lochia) are more indicative of an infection like endometritis.
- Urinary tract infection (UTI):
- Reasoning: The client is voiding frequently without difficulty, and there are no specific urinary symptoms like dysuria or urgency. The presence of foul-smelling lochia and a boggy, tender uterus points more towards endometritis.
- Engorgement:
- Reasoning: While the client’s breasts are firm and heavy, she denies nipple discomfort, and the primary symptoms (fever, chills, malaise, foul-smelling lochia) are more consistent with an infection rather than simple breast engorgement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hypertension is not a common adverse effect of epidural anesthesia. In fact, epidurals can cause hypotension due to the blockade of sympathetic nerves.
Choice B rationale
Tachypnea is not typically associated with epidural anesthesia. Common side effects include low blood pressure and headache.
Choice C rationale
Tachycardia is not a common adverse effect of epidural anesthesia. More common side effects include low blood pressure and urinary retention.
Choice D rationale
Fever is a known adverse effect of epidural anesthesia. It can occur due to the body’s response to the epidural procedure.
Correct Answer is D
Explanation
Choice A rationale
A BP of 132/84 mm Hg is within the normal range for a pregnant woman and does not require immediate reporting.
Choice B rationale
A weight gain of 1 kg (2.2 lb) in one month is within the expected range for a pregnant woman at 26 weeks gestation.
Choice C rationale
Pedal edema is a common symptom in pregnancy and is usually not a cause for concern unless accompanied by other symptoms.
Choice D rationale
Double vision is a concerning symptom that could indicate a serious condition such as preeclampsia. It should be reported to the provider immediately.
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