Question 48.
A client who has undergone a cesarean section is experiencing abdominal pain and tenderness.
Which of the following should the nurse assess for?
Bowel sounds
Lochia amount
Breast tenderness
Urinary output
Signs of peritonitis
The Correct Answer is A
The correct answer is choice E) Signs of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal cavity that can be caused by an infection or a perforation of an organ.
It can cause severe abdominal pain and tenderness, fever, nausea, vomiting, and decreased bowel sounds. Peritonitis is a medical emergency that requires immediate treatment with antibiotics and surgery
Choice A) Bowel sounds is wrong because bowel sounds are normal and expected after a cesarean section.
They indicate that the intestines are functioning properly and moving food and gas through the digestive tract. Bowel sounds may be decreased or absent if there is an obstruction, ileus, or peritonitis
Choice B) Lochia amount is wrong because lochia is the vaginal discharge that occurs after childbirth.
It consists of blood, mucus, and tissue from the uterus.
Lochia amount is not related to abdominal pain and tenderness after a cesarean section.
Lochia amount may vary depending on the stage of lochia (rubra, serosa
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Correct Answer is A
Explanation
The correct answer is choice A) Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding.The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day.Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots.The normal range of lochia rubra is scant to moderate.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Choice C) Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Choice D) Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.
Correct Answer is D
Explanation
The correct answer is D) Decreased white blood cell count.Postpartum endometritis is an infection of the lining of the uterus that causes fever, abdominal pain, uterine tenderness and sometimes discharge.It is usually caused by bacteria from the lower genital or gastrointestinal tract.White blood cell count is a marker of inflammation and infection, so a decreased white blood cell count indicates that the treatment is effective and the infection is resolving.
A) Decreased vaginal bleeding is not a sign of effective treatment for postpartum endometritis.
Vaginal bleeding after delivery is normal and gradually decreases over time.It is not related to the infection of the uterus.
B) Increased abdominal pain is a sign of worsening infection, not effective treatment.Abdominal pain is one of the symptoms of postpartum endometritis and should improve with antibiotic therapy.
C) Increased temperature is also a sign of worsening infection, not effective treatment.Fever is another symptom of postpartum endometritis and should decrease with antibiotic therapy.
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