One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?

Assess the client’s perineal area for signs of a perineal hematoma.

Assess the client’s temperature, pulse, and respirations every 4 hours.

Notify the healthcare provider, since this finding is indicative of infection.

Check the differential, since the WBC is normal for this client.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.

Choice B rationale

Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.

Choice C rationale

While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.

Choice D rationale

A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.

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Correct Answer is B

Explanation

Choice B rationale

When changing a newborn’s diaper, it is recommended to use clear water for cleaning. This is because newborns have sensitive skin, and clear water is gentle and unlikely to cause irritation.

Choice A rationale

Corn starch powder is not typically recommended for use in diaper changes. While it can help absorb moisture, it can also create a paste with the stool that is difficult to clean and can potentially cause skin irritation.

Choice C rationale

Talcum powder is not recommended for use in diaper changes. It can cause respiratory problems if inhaled by the baby.

Choice D rationale

While baby lotion can be used to moisturize a baby’s skin, it is not typically used during diaper changes. It does not have the same cleaning properties as water and can leave a residue on the skin.

A. Measure the size of the scrotal sac for length and width. B. Observe the urethral opening on the surface of the penis when the newborn voids. C. Use a fingertip to palpate the inguinal canal for a weakening or indentation. D. Perform transillumination of the scrotal sac to visualize shadows of the testes.

Correct Answer is C

Explanation

Choice A rationale

Measuring the size of the scrotal sac does not verify the absence of testes.

Choice B rationale

Observing the urethral opening when the newborn voids does not verify the absence of testes.

Choice C rationale

If a testis is not readily identified, a finger sweep should be performed from the anterior iliac crest along the inguinal canal while palpating the scrotum. This is the correct technique to verify the absence of testes.

Choice D rationale

Transillumination of the scrotal sac is not the first step in verifying the absence of testes.

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One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother inquires about what to use when changing her newborn’s diaper. What should the nurse recommend to this mother?

Correct Answer is B

Explanation

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct Answer is C

Explanation

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