A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
Midline episiotomy
Meconium-stained fluid
Gestational hypertension
Placenta previa
The Correct Answer is A
A. A midline episiotomy is a surgical incision made in the perineal area during childbirth. It is recognized as a risk factor for postpartum infection due to the possibility of bacterial contamination during and after delivery. Proper care and monitoring are essential to prevent infection in the site of the incision.
B. meconium-stained fluid, is not typically a risk factor for maternal infection; it is more a concern for the infant's health if aspirated.
C. gestational hypertension, affects blood pressure during pregnancy but does not directly increase the risk of postpartum infection.
D. placenta previa, is a condition where the placenta covers the cervix, which can lead to bleeding but not infection. Therefore, among the given options, a midline episiotomy is the factor that most significantly places the postpartum client at risk for an infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Hypertension is not typically an adverse reaction to magnesium sulfate; this medication is actually used to lower high blood pressure in preeclampsia.
B) Hypoglycemia is also not a common adverse reaction to magnesium sulfate. This medication does not typically affect blood sugar levels.
C) A respiratory rate of 16/min is within normal limits and is not indicative of an adverse reaction to magnesium sulfate, which can cause respiratory depression if it does affect breathing.
D) Urine output of 20 mL/hr is a concerning sign and can indicate nephrotoxicity or acute kidney injury, which are possible adverse reactions to magnesium sulfate, especially in the context of preeclampsia where kidney function must be closely monitored.
Correct Answer is B
Explanation
Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.
Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.
Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.
Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.
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