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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Shortness of breath and chest pain are signs of pulmonary embolism (PE), which is a life-threatening complication of deep vein thrombosis (DVT).DVT is a type of blood clot that can occur in the legs or arms, especially during pregnancy and postpartum.PE happens when a blood clot breaks off and travels to the lungs, blocking blood flow.
Choice B is wrong because nausea and vomiting are not specific signs of thromboembolism.
They can be caused by many other conditions, such as morning sickness, food poisoning, or medication side effects.
Choice C is wrong because headache and blurred vision are not typical signs of thromboembolism.
They can be associated with other pregnancy complications, such as preeclampsia or eclampsia.
Choice D is wrong because fever and chills are not common signs of thromboembolism.
They can indicate an infection or inflammation, such as mastitis or endometritis.
Pregnant women have a higher risk of developing DVT and PE because of hormonal changes, increased blood clotting factors, reduced blood flow to the legs, and other factors.The risk is even higher after a cesarean delivery.
Therefore, it is important to know the signs and symptoms of thromboembolism and seek immediate medical attention if they occur.Thromboembolism can be prevented and treated with anticoagulant medications, compression stockings, and physical activity.
Correct Answer is ["A","B","C","E"]
Explanation
A. "Holding the newborn close to her chest" indicates effective bonding. Physical closeness is important for establishing a connection between the mother and newborn. This promotes emotional attachment and comfort for the baby.
B. "Making eye contact with the newborn" is a key indicator of bonding. Eye contact fosters connection and attachment and is often an early behavior seen in positive bonding.
C. "Talking to the newborn in a soft voice" also reflects positive bonding behavior. Talking to the newborn helps with emotional connection, promotes early communication, and establishes comfort for the baby.
D. "Handing the newborn to a family member when crying" does not indicate effective bonding. While it may be appropriate to ask for help, consistent delegation of newborn care can suggest a lack of emotional connection or reluctance to care for the infant.
E. "Stroking the newborn’s hair and skin" is another indicator of effective bonding. Physical touch, such as stroking, is soothing and promotes attachment between the mother and her newborn.
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