A nurse is monitoring a patient who had a cesarean delivery for signs of infection.
Which of the following findings should alert the nurse to a possible infection? (Select all that apply.).
Temperature of 38°C (100.4°F) or higher
Foul-smelling lochia or increased lochia
Tenderness or hardness in the lower abdomen
Decreased white blood cell count
Increased thirst or dry mouth
Correct Answer : A,B
The correct answer is choice A and B. A temperature of 38°C (100.4°F) or higher and foul-smelling lochia or increased lochia are signs of infection after a C-section. A C-section is a major surgery that involves making incisions in the abdomen and uterus, which can get infected by bacteria. An infection can also affect the lining of the uterus (endometritis) or the urinary tract.
Choice C is wrong because tenderness or hardness in the lower abdomen is normal after a C-section and does not indicate an infection.
Choice D is wrong because a decreased white blood cell count is not a sign of infection. In fact, an increased white blood cell count is more likely to occur with an infection.
Choice E is wrong because increased thirst or dry mouth is not a sign of infection. It could be due to dehydration, medication, or hormonal changes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice D. All of the above interventions should be implemented in the immediate postoperative period after a cesarean delivery.
Choice A is correct because assessing the client’s fundus for firmness and position is important to prevent postpartum hemorrhage and monitor uterine involution.The fundus should be firm and at the level of the umbilicus one hour after delivery and descend into the pelvis at a rate of approximately 1 cm per day.
Choice B is correct because encouraging early ambulation can prevent thromboembolism, which is a potential complication of cesarean delivery.Early mobilization can also reduce pain, ileus, and urinary retention.
Choice C is correct because monitoring the client’s intake and output can help detect fluid imbalance, dehydration, or urinary tract infection.
Fluid intake should be adequate to maintain hydration and support lactation.Urinary output should be at least 30 mL per hour.
Therefore, choice D is correct because all of the above interventions are appropriate for postoperative care after a cesarean delivery.
Correct Answer is ["A","B"]
Explanation
The correct answer is choice A and B.A temperature of 38°C (100.4°F) or higher and foul-smelling lochia or increased lochia are signs of infection after a C-section.A C-section is a major surgery that involves making incisions in the abdomen and uterus, which can get infected by bacteria.An infection can also affect the lining of the uterus (endometritis) or the urinary tract.
Choice C is wrong because tenderness or hardness in the lower abdomen is normal after a C-section and does not indicate an infection.
Choice D is wrong because a decreased white blood cell count is not a sign of infection.In fact, an increased white blood cell count is more likely to occur with an infection.
Choice E is wrong because increased thirst or dry mouth is not a sign of infection.It could be due to dehydration, medication, or hormonal changes.
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