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 D

Explanation

Choice A rationale

Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.

Choice B rationale

Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.

Choice C rationale

Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.

Choice D rationale

Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.

A. Counsel her to increase her caloric intake. B. Advise the client to breastfeed more frequently. C. Inform her that a decreased need for insulin occurs while breastfeeding. D. Schedule an appointment for the client with the diabetic nurse educator.

Correct Answer is C

Explanation

Choice A rationale

While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.

Choice B rationale

Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.

Choice C rationale

Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.

Choice D rationale

While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.

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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 client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

Correct Answer is D

Explanation

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

Correct Answer is C

Explanation

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