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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. 1 cup sliced peaches: Peaches contain some vitamin C but in lower amounts compared with other fruits. They are not the highest source for meeting daily vitamin C needs in toddlers.

B. 1 cup sliced banana: Bananas provide minimal vitamin C and are better known for their potassium content. They are not an effective choice for significantly increasing vitamin C intake.

C. 1 cup sliced kiwifruit: Kiwifruit is exceptionally high in vitamin C, providing more than the daily requirement for a toddler in a single cup. It is an excellent choice for boosting vitamin C intake.

D. 1 cup cubed cantaloupe: Cantaloupe contains vitamin C but in moderate amounts. While beneficial, it is less concentrated than kiwifruit for meeting vitamin C needs.

A. Skin feels cool to the touch. B. Capillary refill 3 seconds in left foot C. Dressing on left hand shows small amount of moisture through gauze. D. Blood pressure 102/50 mm Hg E. Temperature 35.8° C (96.4° F) F. Respiratory rate 20/min G. Output of 25 mL dark amber urine through catheter

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

Explanation

Rationale for correct choices:

Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a parent about increasing vitamin C in her toddler's diet. Which of the following food choices should the nurse recommend as the best source of vitamin C?

Correct Answer is C

Explanation

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

Explanation

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