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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 C

Explanation

A. Complete the assessment while allowing the child to cry. Forcing an examination while the child is distressed can heighten anxiety and reduce cooperation. A preschooler needs reassurance and a gradual approach to feel safe before proceeding with the assessment.
B. Explain to the child the reasons an examination is needed. While providing simple explanations is beneficial, preschoolers may not fully understand medical reasoning. Building trust through interaction and distraction is more effective than verbal explanations alone.
C. Talk to the mother and gradually focus on the child's toy. Preschoolers often feel more comfortable when they see their parent engaging positively with the nurse. Redirecting attention to a familiar toy can help ease anxiety, making the child more willing to cooperate with the assessment. This approach builds trust and minimizes fear.
D. Request extra staff to help with the nursing assessments. Bringing in additional staff may make the child feel more overwhelmed and frightened. Gentle, child-friendly engagement techniques should be attempted first before considering restraint or forceful examination.

A. Diet cola. B. Ice tea. C. Lemonade. D. Milkshake.

Correct Answer is C

Explanation

A. Diet cola. Cola contains caffeine, which can contribute to dehydration by increasing urine output. Hydration is essential for individuals with sickle cell anemia to prevent sickling crises, so choosing a non-caffeinated beverage is a better option.
B. Ice tea. Many iced teas contain caffeine, which can have a diuretic effect and lead to dehydration. Dehydration increases blood viscosity, raising the risk of vaso-occlusive crises in individuals with sickle cell anemia.
C. Lemonade. Lemonade is a hydrating, caffeine-free drink that provides fluids necessary to maintain adequate blood volume and reduce the risk of sickling. Staying well-hydrated is crucial in preventing complications such as vaso-occlusive crises and organ damage in sickle cell disease.
D. Milkshake. While a milkshake provides calories and nutrients, it is thick and high in sugar, which may not be as effective for rapid hydration on a hot day. Proper hydration with clear fluids, such as water or lemonade, is the best option to reduce the risk of dehydration-related sickling.

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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.

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Naxlex Comprehensive Predictor Exams

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?

Exhibits Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.

Exhibits Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse knows that the mastitis in this scenario is most likely caused bydropdown, as evidenced bydropdown

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Exhibits Review H and P, and nurse's note. Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.

The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, "My mother says I should put rice cereal in the baby's bottle now. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

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.