A nurse is collecting data from a client who is 2 days postoperative following abdominal surgery. Which of the following findings is a manifestation that can indicate an infection?

Temperature of 37.2° C (99.0° F)

Increased urinary output

Pain rating of 4 on a scale of 0 to 10

Elevated WBC count

Answer and Explanation

The Correct Answer is D

Postoperative clients require close monitoring for early signs of infection, especially within the first few days after surgery when surgical sites are most vulnerable. Infection can develop due to bacterial contamination, impaired tissue healing, or compromised immunity. Common indicators include systemic inflammatory responses such as fever, leukocytosis, and localized signs at the incision site. Nurses must differentiate normal postoperative changes from findings that suggest infection to ensure timely intervention.

Rationale:
A. A temperature of 37.2°C (99.0°F) is within normal or low-grade postoperative range and does not indicate infection. Mild temperature elevations can occur after surgery due to atelectasis or the inflammatory healing process. It is not a reliable indicator of infection on its own.

B. Increased urinary output is not associated with postoperative infection. In fact, infection or sepsis may initially present with decreased urine output due to poor perfusion. Increased output is more likely related to fluid administration or improved renal perfusion.

C. A pain rating of 4/10 is expected in a postoperative client and is not specific for infection. Postoperative pain typically decreases gradually with healing. Infection-related pain is often worsening, localized, and associated with other inflammatory signs rather than a moderate stable pain score.

D. An elevated WBC count is a key indicator of infection because it reflects the body’s immune response to invading pathogens. In a client who is 2 days post abdominal surgery, leukocytosis may suggest developing surgical site infection or intra-abdominal infection. In conditions involving postoperative monitoring such as Postoperative infection, elevated WBCs warrant further assessment and possible intervention.

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Correct Answer is ["B","C","H"]

Explanation

Assessment of a reproductive-age client with delayed menses, abdominal pain, and vaginal spotting requires urgent evaluation for possible early pregnancy complications such as Ectopic pregnancy or threatened pregnancy loss. The combination of abnormal uterine bleeding, missed menstrual period, and localized abdominal tenderness can indicate an early obstetric emergency before hemodynamic instability develops. Nurses must prioritize findings that suggest potential pregnancy-related pathology rather than stable vital signs or unrelated systems.

Rationale:
A. A temperature of 37.3°C (99.1°F) is within normal limits and does not suggest infection or acute systemic compromise. There are no accompanying signs of sepsis or inflammatory process such as chills, leukocytosis, or worsening vital instability. This finding does not require immediate follow-up in the current clinical context.

B. Vaginal spotting requires immediate follow-up because it may represent abnormal implantation, threatened abortion, or early ectopic pregnancy bleeding. In a client with delayed menses and abdominal pain, even scant dark red bleeding becomes highly significant. This can be an early sign of trophoblastic disruption or tubal irritation, requiring urgent evaluation to rule out pregnancy complications.

C. The menstrual history showing a 2-week delayed period with last menses 6 weeks ago is a critical finding requiring follow-up because it raises suspicion of early pregnancy. When combined with abdominal pain and spotting, it becomes highly suggestive of possible ectopic pregnancy or early pregnancy complication. Establishing gestational status is essential for determining urgency of further diagnostic testing.

D. Hyperactive bowel sounds alone are not specific for obstetric emergencies and may be influenced by anxiety, diet, or mild gastrointestinal activity. Although abdominal conditions can sometimes coexist, bowel sounds are not the primary indicator of early pregnancy complications. Therefore, this finding is less urgent compared to bleeding and menstrual changes.

E. A heart rate of 90/min is within normal limits and does not indicate hemodynamic instability. There are no signs of shock such as tachycardia, hypotension, or altered mental status. This finding does not require immediate intervention in this context.

F. Slight inspiratory wheezes are consistent with the client’s known asthma history and are not currently causing respiratory compromise. Oxygenation is stable, and there is no acute respiratory distress. This finding is not a priority compared to reproductive system concerns.

G. Oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no evidence of respiratory dysfunction requiring intervention. This value is stable and not clinically urgent.

H. Abdominal tenderness, particularly in the right lower quadrant, requires immediate follow-up because it may indicate implantation in the fallopian tube or irritation from ectopic pregnancy. When combined with delayed menses and vaginal spotting, it becomes highly concerning for a potentially life-threatening condition. Early identification is critical to prevent rupture and internal hemorrhage.

A. Bright red vaginal bleeding B. Rigid abdomen C. Increased fetal movement D. Persistent uterine contractions

Correct Answer is A

Explanation

Placenta previa is a pregnancy complication in which the placenta implants low in the uterus and partially or completely covers the cervical os. This abnormal positioning can lead to painless vaginal bleeding, especially in the second or third trimester as the cervix begins to efface and dilate. The condition poses a risk for maternal hemorrhage and fetal compromise due to disruption of placental attachment. Clinical management focuses on bleeding assessment, fetal monitoring, and preventing further cervical irritation.

Rationale:
A. Bright red vaginal bleeding is the hallmark finding of Placenta previa. The bleeding is typically painless and results from placental separation as the lower uterine segment stretches. The bright red color indicates fresh arterial bleeding, which is a key distinguishing feature from other obstetric emergencies.

B. A rigid abdomen is more commonly associated with placental abruption rather than placenta previa. In abruption, the placenta detaches prematurely, causing uterine tenderness and a board-like abdomen. Placenta previa typically presents without abdominal pain or uterine rigidity.

C. Increased fetal movement is not a typical finding in placenta previa and does not indicate pathology specific to this condition. Fetal movement patterns may vary but are not diagnostic or expected as a clinical sign of placenta previa. In severe cases of bleeding, fetal activity may actually decrease due to hypoxia.

D. Persistent uterine contractions are not characteristic of placenta previa. The uterus is usually soft and non-tender, and contractions are not a defining feature. If contractions occur, they may suggest labor or another obstetric complication rather than placenta previa.

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A nurse is collecting data from a client who is 2 days postoperative following abdominal surgery. Which of the following findings is a manifestation that can indicate an infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

Correct Answer is ["B","C","H"]

Explanation

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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