Try Naxlex NCLEX-RN (Free-Trial)

A nurse on a postpartum unit is caring for a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Vital Signs:

Postpartum day 3, 0815:

Temperature 38.2° C (100.8° F)

Heart rate 104/min

Respiratory rate 18/min

BP 108/70 mm Hg

SaO2 97% on room air

Nurses' Notes:

Postpartum day 3, 0815:

Client reports feeling unwell.

Lung sounds clear but diminished in the bases.

Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding.

Uterus firm at 1 cm above the umbilicus and tender to palpation.

Fundus boggy but firmed with massage.

Moderate amount of dark brown, foul-smelling lochia noted.

Surgical incision well approximated with slight edema present; no redness or drainage noted.

No bowel movement since birth, hypoactive bowel sounds.

Diagnostic Results:

Postpartum day 3, 0900:

Hemoglobin 11.1 g/dL (greater than 11 g/dL)

WBC count 33,000/mm3 (5,000 to 10,000/mm)

Temperature 38.2° C (100.8° F)

Heart rate 104/min

BP 108/70 mm Hg

SaO2 97% on room air

Client reports feeling unwell

Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding

Uterus firm at 1 cm above the umbilicus and tender to palpation

Moderate amount of dark brown, foul-smelling lochia noted

Surgical incision well approximated with slight edema present; no redness or drainage noted

WBC count 33,000/mm3 (5,000 to 10,000/mm)

Answer and Explanation

The Correct Answer is ["A","B","E","G","H","J"]

Rationale for correct choices

• Temperature 38.2° C (100.8° F): A temperature above 38° C after the first 24 hours postpartum is concerning for infection. This client has multiple risk factors including cesarean delivery and prolonged rupture of membranes. Fever in this patient warrants immediate evaluation for postpartum endometritis or mastitis.

• Heart rate 104/min: Tachycardia can indicate a systemic inflammatory or infectious process in the postpartum period. When paired with fever and uterine tenderness, it raises concern for sepsis or worsening uterine infection. Early recognition is critical to prevent complications.

• Client reports feeling unwell: A subjective report of feeling unwell is an important early sign of infection or systemic illness. This symptom, combined with abnormal vital signs and laboratory findings, suggests the client may be developing a postpartum complication requiring prompt intervention.

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness beyond the immediate postpartum period is abnormal and commonly associated with endometritis. The elevated fundal height also suggests delayed uterine involution, reinforcing concern for uterine infection.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a classic indicator of postpartum uterine infection. Normal lochia should not have an offensive odor, and this finding strongly supports suspected endometritis requiring immediate follow-up.

• WBC count 33,000/mm³: Although mild leukocytosis is expected postpartum, a WBC count this elevated exceeds normal physiologic changes. In the presence of fever and uterine findings, this level is highly suggestive of an acute infectious process.

Rationale for incorrect choices

• Breasts feel firm, heavy, and warm with moderate nipple discomfort: These findings are consistent with normal breast engorgement during early breastfeeding. While uncomfortable, they are expected postpartum changes and do not indicate infection in the absence of localized redness or systemic signs.

• Surgical incision well approximated with slight edema present: Mild edema without redness, drainage, or separation is a normal postoperative finding. There are no signs suggesting a surgical site infection at this time.

• Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97%: These vital signs fall within expected postpartum ranges and do not indicate acute instability. They do not contribute to the immediate concern for infection or deterioration.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Request an interpreter of a different sex from the client: The sex of the interpreter should generally match the client’s preference to ensure comfort and cultural sensitivity. Automatically choosing a different sex could cause distress or reduce effective communication.

B. Direct attention toward the interpreter when speaking to the client: The nurse should speak directly to the client, maintaining eye contact and addressing them personally, rather than focusing on the interpreter. This promotes engagement and respects the client’s autonomy.

C. Review the facility policy about the use of an interpreter: Understanding the facility’s interpreter policies ensures the nurse follows proper procedures for obtaining professional language services, maintains confidentiality, and delivers accurate and effective communication for informed consent and care planning.

D. Request a family member or friend to interpret information for the client: Using family or friends as interpreters is discouraged due to risks of miscommunication, bias, or breach of confidentiality. Professional interpreters ensure accurate, unbiased communication.

A. Elevate the head of the client's bed to 45°. B. Change the client's dressing 4 hr following the procedure. C. Assess the client's peripheral pulses every 15 min. D. Instruct the client to flex the right knee every 30 min.

Correct Answer is C

Explanation

A. Elevate the head of the client's bed to 45°: After a femoral cardiac catheterization, the client should remain supine with the affected leg straight to prevent bleeding or hematoma formation. Elevating the head too much can increase the risk of vascular complications.

B. Change the client's dressing 4 hr following the procedure: The initial dressing should remain intact for the time specified by the provider, usually 24 hours, unless it becomes soiled or saturated. Early dressing changes can disrupt the insertion site and increase bleeding risk.

C. Assess the client's peripheral pulses every 15 min: Frequent assessment of peripheral pulses in the affected extremity is essential to detect early signs of compromised circulation, hematoma, or arterial occlusion following femoral access. Monitoring every 15 minutes immediately post-procedure aligns with best practice.

D. Instruct the client to flex the right knee every 30 min: Clients are instructed to keep the affected leg straight to prevent disruption of the femoral access site and minimize bleeding. Flexing the knee increases the risk of hematoma formation and vascular injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative immediately following a cardiac catheterization with a right femoral approach. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

A nurse is providing care for a client who is experiencing an acute exacerbation of systemic lupus erythematosus. Which of the following findings should the nurse anticipate?

A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy. Complete the following sentence by using the lists of options. The child is at risk for developing dropdown as evidenced by their dropdown and dropdown.