The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?
White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)
Moderate amount of foul-smelling lochia.
Blood pressure of 122/74 mm Hg
Oral temperature of 100.2°F (37.9°C..
White blood cell count of 19,000/mm^3 (19 x 10^9/L)
The Correct Answer is A
Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.
Choice C reason: Oral temperature of 100.2°F (37.9°C. is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.
Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D: Keeping the chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.
Correct Answer is D
Explanation
Choice A: Assessing pupillary response to light hourly is not an intervention that the nurse should implement while administering dopamine, as this is not related to the effects or side effects of dopamine. This is a distractor choice.
Choice B: Initiating seizure precautions is not an intervention that the nurse should implement while administering dopamine, as this is not a common or expected complication of dopamine. This is another distractor choice.
Choice C: Monitoring serum potassium frequently is not an intervention that the nurse should implement while administering dopamine, as this is not affected by dopamine or hypotension. This is another distractor choice.
Choice D: Measuring urinary output every hour is an intervention that the nurse should implement while administering dopamine, as this can indicate the effectiveness of dopamine in improving renal perfusion and blood pressure. Therefore, this is the correct choice.
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