A nurse is collecting data from a client who is 2 days postpartum. Which of the following findings should alert the nurse to the possibility of a puerperal infection?

Upper abdominal pain

Bradycardia

Hypothermia

Foul-smelling lochia

Answer and Explanation

The Correct Answer is D

A.   Upper abdominal pain could indicate a variety of issues, including gastrointestinal upset or muscle soreness from labor, but it is not specific to a puerperal infection.
B.   Bradycardia (slow heart rate) is not typically associated with a puerperal infection.
C.   Hypothermia (low body temperature) is not a typical sign of a puerperal infection.
D.   Foul-smelling lochia can be indicative of an infection, as an unpleasant odor may be associated with bacterial growth in the uterine cavity. This is a concerning sign and should be further evaluated.

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Correct Answer is B

Explanation

A. Multiple gestation is associated with elevated levels of alpha-fetoprotein, not low levels.
B. Down syndrome is associated with low levels of alpha-fetoprotein.

C. Intrauterine growth restriction is not directly associated with maternal serum alpha-fetoprotein levels.
D. High levels of maternal serum alpha fetoprotein indicate a neurl tube defect such as spina bifida

A. Administer the medication into the deltoid muscle. B. Check the mother's Rh factor prior to administration. C. Administer the medication 12 hr after birth. D. Administer the medication with a 25 gauge needle.

Correct Answer is D

Explanation

A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.

B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.

C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.

D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.

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A nurse is collecting data from a client who is 2 days postpartum. Which of the following findings should alert the nurse to the possibility of a puerperal infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing a client's maternal serum alpha-fetoprotein screening results with a newly licensed nurse. Which of the following conditions is associated with low levels?

Correct Answer is B

Explanation

A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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