A nurse is caring for the client.

Select the 5 findings that indicate the client's condition has improved.

WBC count

Heart rate

Fundal height

Temperature

Hgb

Lochia

Answer and Explanation

Correct Answer : A,B,C,D,F

A. WBC count: The client’s WBC count decreased from 33,000/mm³ to 10,000/mm³, returning to the expected postpartum reference range. This decline indicates resolution of the infectious or inflammatory process, consistent with effective antibiotic therapy for postpartum infection such as endometritis.

B. Heart rate: The heart rate decreased from tachycardic values (104–110/min) to 78/min, which is within normal limits. Resolution of tachycardia suggests improvement in systemic stress, infection, and overall hemodynamic stability.

C. Fundal height: The fundus progressed from being above the umbilicus to 4 cm below the umbilicus, demonstrating appropriate uterine involution. This finding reflects improved uterine tone and reduced risk of postpartum hemorrhage or ongoing uterine infection.

D. Temperature: The client’s temperature normalized from febrile readings (38.2–38.6°C) to 37.1°C. Resolution of fever is a key indicator of infection control and clinical improvement following antimicrobial treatment.

E. Hgb: Hemoglobin decreased from 11.1 g/dL to 10 g/dL, which does not indicate improvement. This trend suggests ongoing physiologic postpartum blood loss or dilution and does not reflect recovery.

F. Lochia: Lochia changed from dark brown with foul odor to a small amount of brownish-red lochia without odor. This improvement indicates resolution of uterine infection and normalization of postpartum uterine discharge.

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Free Nursing Study Resources

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

Explanation

Rationale:

• Obtain daily weights: Daily weights are used to monitor fluid balance in conditions like preeclampsia or heart failure. In this acute preterm labor scenario, the priority is monitoring fetal well-being and uterine activity, not long-term fluid shifts.

• Administer terbutaline: Terbutaline is a tocolytic medication used to suppress preterm labor by relaxing uterine smooth muscle. Given the client’s regular, strong contractions at 33 weeks with cervical changes, terbutaline may be prescribed to delay labor and allow fetal maturation.

• Administer oxytocin: Oxytocin stimulates uterine contractions and is used to induce or augment labor. In a client experiencing preterm labor at 33 weeks, oxytocin is contraindicated because it could worsen labor progression and increase risk of preterm birth.

• Administer betamethasone: Betamethasone is a corticosteroid administered to accelerate fetal lung maturity when preterm birth is imminent. Since the client is 33 weeks gestation and showing signs of preterm labor, administration is anticipated to reduce neonatal respiratory complications.

• Maintain modified bed rest with bathroom privileges: Modified bed rest can help reduce uterine stimulation, conserve energy, and support uteroplacental perfusion in clients experiencing preterm labor. Limiting physical activity is a standard intervention for preterm labor management.

A. Fold the top of the stocking over neatly. B. Massage the client's legs once every 8 hr while the stockings are in place. C. Determine if the stockings are binding. D. Apply the stockings after the client is in a chair.

Correct Answer is C

Explanation

A. Fold the top of the stocking over neatly: Folding the top of antiembolic stockings can create a tourniquet effect, restricting venous return and increasing the risk of skin injury or deep vein thrombosis. Stockings should lie flat without folds to maintain proper circulation.

B. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs while antiembolic stockings are on is contraindicated because it can dislodge a thrombus if present, potentially causing a pulmonary embolism. Leg massage should be avoided in clients at risk for thromboembolic events.

C. Determine if the stockings are binding: Assessing whether the stockings are binding or causing constriction is essential. Improperly fitted stockings can impair circulation, lead to skin breakdown, and reduce the prophylactic effect against venous thromboembolism.

D. Apply the stockings after the client is in a chair: Antiembolic stockings should be applied while the client is supine with legs elevated to prevent edema and ensure even pressure distribution. Applying them while seated can reduce effectiveness and increase the risk of skin injury.

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A nurse is caring for the client. Select the 5 findings that indicate the client's condition has improved.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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A nurse is caring for the client.

Select the 5 findings that indicate the client's condition has improved.