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A nurse is caring for the client.

Exhibits

Nurses' Notes

Postpartum Day 3, 0815:

Client reports feeling unwell. Lung sounds clear but diminished in the bases. Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding. Uterus firm at 1 cm above the umbilicus and tender to palpation. Fundus boggy but firmed with massage. Moderate amount of dark brown, foul-smelling lochia noted. Surgical incision well approximated with slight edema present; no signs of infection noted. No bowel movement since birth, hypoactive bowel sounds

Vital Signs

Postpartum Day 3, 0815:

Temperature 38.2° C (100.8° F)

Heart rate 104/min

Respiratory rate 18/min

BP 108/70 mm Hg

SaO2 97% on room air

Diagnostic Results

Postpartum Day 3, 0900:

Hemoglobin 11.1 g/dL

WBC count 33,000/mm3

Uterus firm at 1 cm above the umbilicus and tender to palpation.

Moderate amount of dark brown, foul-smelling lochia noted

Surgical incision well approximated with slight edema present

Temperature 38.2° C (100.8° F)

Respiratory rate 18/min

SaO2 97% on room air

WBC count 33,000/mm3

Answer and Explanation

The Correct Answer is ["A","B","D","G"]

Rationale for Correct Answers:

Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.

B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.

C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.

D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.

A. Maintain the irrigation solution rate. B. Warm the irrigation solution. C. Perform the Credé's maneuver. D. Replace the indwelling urinary catheter.

Correct Answer is A

Explanation

Rationale:

A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.

B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.

C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.

D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

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A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

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A nurse is teaching a female client about personal hygiene. Which of the following client actions indicates an understanding of teaching?

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.