The nurse is receiving report on a postpartum client who gave birth two days ago after a prolonged rupture of membranes and is currently having an increase in perineal pain.
What postpartum complication does the nurse assess for in the client?
Peritonitis.
Thrombophlebitis.
Infection of perineum.
Endometritis.
The Correct Answer is C
Choice A rationale
Peritonitis is a severe inflammation of the peritoneum, the membrane lining the abdominal cavity, usually due to bacterial contamination from a perforated viscus or the uterus. While a serious complication of advanced puerperal infection, peritonitis presents with generalized severe abdominal rigidity, rebound tenderness, and high fever, not just an increase in localized perineal pain, which is the key symptom described.
Choice B rationale
Thrombophlebitis (or superficial vein thrombosis) involves inflammation and clotting in a vein, most commonly in the legs post-delivery. It presents with localized warmth, redness, swelling, and pain along the course of the affected vein in the calf or thigh, not primarily with increased localized pain in the perineal region, which is the anatomical area described in the report.
Choice C rationale
Infection of the perineum (often related to an episiotomy, laceration repair, or hematoma) is highly likely given the combination of a prolonged rupture of membranes (a risk factor) and the specific complaint of increasing perineal pain two days postpartum. Infection leads to localized inflammation, edema, purulent drainage, and increased pain at the perineal wound site, matching the client's symptoms and risk profile.
Choice D rationale
Endometritis is an infection of the uterine lining (endometrium), a common postpartum complication, especially after prolonged rupture of membranes. Classic signs include fever, uterine subinvolution, and foul-smelling lochia, often accompanied by lower abdominal or uterine tenderness, but increasing perineal pain points more specifically to a localized wound infection or abscess in that area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["150"]
Explanation
Step 1 is: Calculate the infusion rate change per hour. 4 grams/hr is the initial rate, and it is titrated by 1 gram/hr every hour. The infusion started at 0800. At 0900 (1 hour later), the rate is 4 grams/hr + 1 gram/hr = 5 grams/hr. At 1000 (2 hours later), the rate is 5 grams/hr + 1 gram/hr = 6 grams/hr. At 1100 (3 hours later), the rate is 6 grams/hr + 1 gram/hr = 7 grams/hr. At 1200 (4 hours later), the rate is 7 grams/hr + 1 gram/hr = 8 grams/hr. At 1300 (5 hours later), the rate is 8 grams/hr + 1 gram/hr = 9 grams/hr.
Step 2 is: Calculate the final rate in mL/hr using the concentration and the final grams/hr rate. The concentration is 60 grams÷ 1000 mL. The rate at 1300 is 9 grams/hr. 9 grams/hr× (1000 mL÷ 60 grams). 9000 mL/hr÷ 60. 150 mL/hr. The rate of infusion at 1300 is 150.
Correct Answer is C
Explanation
Choice A rationale
The "taking in" phase immediately follows birth and typically lasts 1-2 days. During this period, the mother is largely passive and dependent, focusing on her own needs for rest and nourishment, and reliving the birth experience. She is often content to let others provide care for the infant while she rests and recovers.
Choice B rationale
The "letting go" phase is the final phase, occurring once the mother has settled at home, and involves the mother moving forward as a family unit. This phase involves relinquishing the previous childless lifestyle and adapting to her new role, including accepting the infant's increasing independence and addressing relationship changes with her partner.
Choice C rationale
The "taking hold" phase usually begins on the second or third day and lasts for several weeks. The mother becomes more independent and actively focused on the newborn's needs, exhibiting a strong interest in learning and taking charge of infant care. Asking multiple questions about care is a hallmark of this phase.
Choice D rationale
Early parenting is a broader, less specific term than the Reva Rubin's three-stage framework. While the behavior is certainly a part of early parenting, the phases ("taking in," "taking hold," and "letting go") specifically describe the mother's psychological adjustment to her new role and are the correct terminology for this specific behavioral stage.
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