A nurse is collecting data from a patient who gave birth one week ago.
Which of the following findings should the nurse identify as a manifestation of endometritis?

Increased heart rate.

Decreased appetite.

Swelling in the ankles.

Dry skin.

Answer and Explanation

The Correct Answer is C

Choice C rationale:

Endometritis is an inflammation of the inner lining of the uterus (endometrium). It is a common complication after childbirth,

affecting up to 1 in 10 women who deliver vaginally. Symptoms of endometritis typically develop within 1-3 days after

childbirth, but they can sometimes take up to a week to appear.

Swelling in the ankles is a common symptom of endometritis. This is because endometritis can cause inflammation and fluid

buildup in the pelvis, which can put pressure on the veins in the legs and cause them to swell.

Choice A rationale:

An increased heart rate can be a symptom of endometritis, but it is not a specific symptom. An increased heart rate can also be

caused by many other factors, such as fever, dehydration, and anxiety.

Choice B rationale:

Decreased appetite can be a symptom of endometritis, but it is not a specific symptom. Decreased appetite can also be caused

by many other factors, such as pain, fatigue, and nausea.

Choice D rationale:

Dry skin is not a typical symptom of endometritis. Dry skin can be caused by many other factors, such as dehydration,

medications, and underlying medical conditions.

Therefore, the most likely manifestation of endometritis in this patient is swelling in the ankles.

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Correct Answer is C

Explanation

The correct answer is choice c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.

Choice A rationale:

This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages.

Choice B rationale:

This choice correctly states the cervix is dilated 3 cm and effaced 30%, but it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.

Choice C rationale:

This choice correctly states that the cervix is dilated 3 cm, effaced 30%, and the presenting part is 1 cm above the ischial spines. This matches the documentation provided.

Choice D rationale:

This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages. Additionally, it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.

A. You should push continuously throughout the entire contraction B. Take a deep, cleansing breath before and after each contraction C. I will let you know when you should push according to your contractions D. Hold your breath and push while I count to ten

Correct Answer is B

Explanation

Choice A rationale:

Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.

Choice B rationale:

Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.

This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.

Choice C rationale:

While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that

can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural

instincts.

Choice D rationale:

Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary

strain and doesn’t take into account the individual rhythms and responses of the mother’s body.

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A nurse is collecting data from a patient who gave birth one week ago.Which of the following findings should the nurse identify as a manifestation of endometritis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

Correct Answer is B

Explanation

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A nurse is collecting data from a patient who gave birth one week ago.
Which of the following findings should the nurse identify as a manifestation of endometritis?