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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?

A.

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

B.

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

C.

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

D.

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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Related Questions

Correct Answer is ["6"]

Explanation

The correct answer is calculated as follows:

Step 1: Identify the total amount of oxytocin in the IV bag. The bag contains 20 units of oxytocin in 1 liter (or 1000 mL) of lactated Ringer’s solution.

Step 2: Convert the oxytocin units to milliunits. 1 unit = 1000 milliunits, so 20 units = 20,000 milliunits.

Step 3: Calculate the concentration of the oxytocin solution in milliunits/mL. Divide the total amount of oxytocin in milliunits by the total volume of the solution in mL.

So, 20,000 milliunits ÷ 1000 mL = 20 milliunits/mL.

Step 4: Calculate the infusion rate in mL/hour. The prescription is for an infusion rate of 2 milliunits/min. Since the concentration of the solution is 20 milliunits/mL, we divide the prescribed rate by the concentration to get the rate in mL/min. So, 2 milliunits/min ÷ 20 milliunits/mL = 0.1 mL/min.

Step 5: Convert the infusion rate to mL/hour. Multiply the rate in mL/min by the number of minutes in an hour. So, 0.1 mL/min × 60 min/hour = 6 mL/hour. Therefore, the nurse should program the infusion pump to deliver 6 mL/hour.

Correct Answer is ["300"]

Explanation

Step 1:

4 grams ÷ 20 grams × 500 mL = 100 mL

Step 2:

100 mL ÷ 20 minutes × 60 minutes/hour = 300 mL/hour

Answer:

300 mL/hour

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