A nurse on a postpartum unit is caring for a client.
Complete the following sentence by using the lists of options.
The client is most likely experiencing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}
- Endometritis – This uterine infection is one of the most common postpartum complications, especially following cesarean delivery and prolonged rupture of membranes. It often presents with foul-smelling lochia, uterine tenderness, and systemic signs of infection like fever and leukocytosis. This client’s presentation, including foul-smelling lochia and a WBC of 33,000/mm³, strongly supports this diagnosis.
- Mastitis – Typically associated with localized breast pain, redness, swelling, and systemic symptoms like fever. While the client has nipple discomfort and firm breasts, these are common postpartum findings during milk let-down and do not meet the criteria for mastitis, especially without signs of inflammation or localized breast infection.
- Pulmonary embolism – A PE generally presents with sudden-onset chest pain, dyspnea, tachypnea, and hypoxia. This client’s oxygen saturation is normal, lung sounds are clear, and there is no respiratory distress, making PE unlikely.
- Postpartum hemorrhage – Hemorrhage would present with excessive vaginal bleeding, hypotension, tachycardia, and possibly uterine atony. This client’s uterus is firm, lochia is moderate (not heavy), and vital signs are stable, so hemorrhage is not supported by the data.
- Lochia assessment – Foul-smelling lochia is a classic indicator of uterine infection. It points to endometritis when found with other risk factors like cesarean birth, prolonged labor, and signs of systemic inflammation.
- Elevated white blood cell count – A postpartum WBC count may be mildly elevated, but a level of 33,000/mm³ suggests infection. When combined with clinical symptoms like uterine tenderness and malodorous discharge, it supports a diagnosis of endometritis.
- Firm uterus at 1 cm above umbilicus – This finding is expected on postpartum day 3 and indicates normal uterine involution. A firm uterus rules out uterine atony and is not specific to infection or hemorrhage.
- Moderate nipple discomfort – Breast fullness and nipple tenderness are common in breastfeeding mothers, especially in the early postpartum period. This discomfort alone does not indicate mastitis or any systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tell the nurses that the assignments will be more equitable in the future. While this acknowledges their concern, it does not involve the nurses in the resolution process or address the root of the conflict through direct communication.
B. Ask each nurse to take turns making the assignments. This may temporarily reduce tension but avoids addressing the underlying issues of perceived favoritism and does not encourage collaboration or accountability.
C. Encourage collaboration between the two nurses when making the assignments. This approach promotes open communication, mutual understanding, and shared decision-making, which are key elements of collaborative conflict resolution. It allows both nurses to express their perspectives and work toward a fair and balanced outcome.
D. Arrange for the nurses to have as few shifts together as possible. This strategy avoids the conflict rather than resolving it, which may only delay or worsen interpersonal issues over time. It also limits opportunities for growth and team building.
Correct Answer is D,B,C,A
Explanation
D. Rolls from back to side usually occurs around 4 months of age as the infant begins developing trunk strength.
B. Rolls from back to abdomen typically follows at around 5 to 6 months, indicating improved coordination and strength.
C. Sits steadily unsupported usually develops around 8 months, showing advanced balance and postural control.
A. Changes from prone to sitting is a more complex skill that typically appears around 10 months, requiring significant core strength and motor planning.
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