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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Naloxone (Narcan) is a specific opiate antagonist that can reverse respiratory depression in newborn infants that may be due to transplacentally acquired opiates.It can be given intravenously, intramuscularly, intraosseously or subcutaneously.The recommended dose is 100 microgram/kg.
Choice B is wrong because nalbuphine (Nubain) is a mixed opiate agonist-antagonist that can cause respiratory depression and withdrawal symptoms in opioid-dependent mothers and infants.
Choice C is wrong because butorphanol (Stadol) is another mixed opiate agonist-antagonist that can have similar effects as nalbuphine.
Choice D is wrong because fentanyl (Sublimaze) is a synthetic opioid that can cause respiratory depression and sedation in both mothers and infants.
Normal ranges for respiratory rate in newborn infants are 30 to 60 breaths per minute.
Normal ranges for oxygen saturation in newborn infants are 90% to 100%.
Correct Answer is E
Explanation
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours.This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention.A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots.However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding.A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside.However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some
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