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Exhibits

The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet.

Select the findings that will help the nurse determine what is causing the client's symptoms.

Rupture of membranes for 16 hours

Normal spontaneous vaginal birth

Breastfeeding 7 to 8 times a day for 10 minutes

Discharge hemoglobin of 9.2 g/dL (92 g/L)

Current vital signs

Shopping yesterday for 5 hours

Foul-smelling lochia rubra

Answer and Explanation

Correct Answer : A,D,E,F,G

A.   Rupture of membranes for 16 hours – The risk of postpartum infection, particularly endometritis, increases with prolonged rupture of membranes because bacteria can ascend into the uterus after the amniotic sac is broken. Although infection risk is higher after 18 hours, 16 hours still poses a concern, especially when combined with other signs of infection.
B.   Normal spontaneous vaginal birth – A vaginal delivery is a routine event that does not inherently increase the risk of infection unless complicated by prolonged labor, excessive blood loss, or retained placental fragments. While it is relevant to the patient’s history, it does not directly contribute to the current symptoms.
C.   Breastfeeding 7 to 8 times a day for 10 minutes – While frequent nursing can sometimes contribute to sore nipples, it does not directly indicate an infection unless there are additional signs of inadequate emptying or poor latch.
D.   Discharge hemoglobin of 9.2 g/dL (92 g/L) – A postpartum hemoglobin level lower than 11 g/dL suggests anemia, which can lead to fatigue, dizziness, and a weakened immune response. While anemia does not directly cause infection, it can contribute to the client’s symptoms of fatigue and dizziness and make it harder for the body to fight infections.
E.   Current vital signs – The presence of fever (101.2°F/38.4°C) and tachycardia (105 beats/min) indicates a systemic inflammatory response, strongly suggesting an active infection. Given the combination of fever, chills, and breast tenderness, mastitis is a likely concern. Additionally, the foul-smelling lochia raises suspicion for endometritis.
F.   Shopping yesterday for 5 hours – Being away from the baby for an extended period may have led to milk stasis, increasing the risk of mastitis. When milk is not regularly emptied, bacterial overgrowth can occur, leading to inflammation and infection, which aligns with the red, warm, firm area on the breast.
G. Foul-smelling lochia rubra – Lochia rubra persisting at two weeks postpartum, particularly with a foul odor, is a classic sign of endometritis, a postpartum uterine infection. Normal postpartum bleeding transitions from rubra to serosa, and foul-smelling discharge indicates bacterial overgrowth in the uterus, requiring prompt antibiotic treatment.

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Correct Answer is ["A","D","F"]

Explanation

A. Blood type: While important for transfusions, blood type is not relevant to assessing pain or determining appropriate pain management strategies. Pain assessment focuses on physiological and behavioral cues, not blood compatibility.
B. Parents’ religious affiliation: Religious beliefs may influence pain management preferences (e.g., preference for non-pharmacologic methods), but this is not a priority assessment before implementing pain management strategies. The immediate focus should be on assessing the infant’s pain level and physiological status.
C. Blood pressure: Pain can cause increased sympathetic nervous system activity, leading to elevated blood pressure. Monitoring blood pressure helps assess the severity of pain and guides appropriate pain management interventions.
D. Level of consciousness: Infants in significant pain may become restless, irritable, or inconsolable, while excessive sedation from pain medications can cause decreased responsiveness. Assessing level of consciousness helps ensure that pain relief measures do not cause over-sedation or respiratory depression.
E. Hearing acuity: Hearing assessment is not relevant for pain management in a 4-month-old infant. Pain assessment in infants focuses on physiological signs, crying, and behavioral responses, rather than auditory abilities.
F. Heart rate: Pain can lead to tachycardia due to sympathetic nervous system activation. Monitoring heart rate helps assess pain intensity and evaluate the effectiveness of pain relief interventions.
G. Deep tendon reflexes: Reflex testing is used for neurological assessment but is not relevant to pain management. Reflexes do not provide direct information about pain intensity or response to treatment.

A. "We should be sure to start our daughter on birth control pills." B. "Sexual maturity differences between my daughter and her peers will disappear within a few years." C. "Our daughter will be on this hormone treatment the rest of her life." D. "We should encourage her to dress in clothing that suits her sexual maturity level."

Correct Answer is B

Explanation

A. "We should be sure to start our daughter on birth control pills." Precocious puberty is caused by early activation of the hypothalamic-pituitary-gonadal axis, not by sexual activity. LHRH therapy suppresses premature puberty, delaying further sexual development until an appropriate age. Birth control pills are unnecessary and not part of the treatment plan.
B. "Sexual maturity differences between my daughter and her peers will disappear within a few years." LHRH therapy works by downregulating the pituitary gland, halting the premature secretion of sex hormones. This delays further development, allowing the child’s physical maturity to align more closely with peers over time. Once treatment is stopped at an appropriate age, normal puberty resumes.
C. "Our daughter will be on this hormone treatment the rest of her life." LHRH therapy is used temporarily to suppress early puberty until an age-appropriate time for normal pubertal progression. Once discontinued, the child will go through puberty naturally, so lifelong treatment is not necessary.
D. "We should encourage her to dress in clothing that suits her sexual maturity level." While psychological and social support is important, the goal of treatment is to delay sexual development, helping the child match her peers. Encouraging age-appropriate behavior and attire rather than emphasizing sexual maturity is more beneficial for the child’s emotional well-being.

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Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

Correct Answer is ["A","D","F"]

Explanation

An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?

Correct Answer is B

Explanation

During the admission procedure of a school age child, the child states, "I'm going to have an operation." Which response is best for the nurse to provide to this child?

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Which drink choice on a hot day indicates to the nurse that an adolescent with sickle cell anemia understands dietary considerations related to the disease?

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The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?

Exhibits

The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet.

Select the findings that will help the nurse determine what is causing the client's symptoms.