The nurse is reviewing discharge instructions with the postpartum client who had a cesarean section 4 days ago and will include which of the following warning signs to report once she is home?
Red, tender area on breast.
Temperature of 100.8°F.
Burning on urination.
Increased lochia rubra.
Correct Answer : A,B,C,D
Choice A rationale
A red, tender area on the breast could indicate mastitis, an infection of the breast tissue. This requires prompt medical attention to prevent complications and provide appropriate treatment, often involving antibiotics.
Choice B rationale
A temperature of 100.8°F is considered a fever and could indicate an infection. Postpartum clients are at risk of infections, including endometritis, and should report any fever to their healthcare provider for further evaluation.
Choice C rationale
Burning on urination could indicate a urinary tract infection (UTI). UTIs are common postpartum due to catheter use and trauma during delivery. This symptom should be reported for evaluation and treatment if necessary.
Choice D rationale
Increased lochia rubra can indicate postpartum hemorrhage or retained placental fragments. Any significant change in bleeding pattern should be reported to ensure timely management and prevent serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Keeping the baby's bassinet away from fans is good practice to avoid drafts that could make the baby cold. Maintaining a stable environment is important for newborns to help regulate their body temperature effectively.
Choice B rationale
Checking the baby's temperature rectally every 3 hours is unnecessary and potentially harmful. Rectal temperature checks are invasive and not typically needed unless directed by a healthcare provider. Axillary temperature is safer and more commonly recommended.
Choice C rationale
Keeping the baby's head covered can help maintain body temperature, especially in cooler environments. Newborns can lose heat quickly through their heads, so this practice is beneficial to keep them warm.
Choice D rationale
Placing the baby on the stomach and covering with a warm blanket is not recommended for sleeping due to the risk of sudden infant death syndrome (SIDS). Babies should be placed on their backs to sleep to reduce this risk. .
Correct Answer is D
Explanation
Choice A rationale
Simply reassuring the parents does not provide them with actions they can take to support their baby's care. While reassurance is important, it must be paired with practical advice that empowers the parents and involves them in the baby's care.
Choice B rationale
Discharge teaching on SIDS prevention is essential but is premature for parents with a 24-week preemie in NICU. The immediate focus should be on supporting them with current care practices and preparing them for future involvement in their baby's daily needs.
Choice C rationale
Discussing diapering, skin, and umbilical cord care is important, but it is not the immediate priority in the NICU context. Parents need guidance on how to support their baby’s current complex care needs rather than routine newborn care at this stage.
Choice D rationale
Emphasizing the importance of pumping breast milk is the most appropriate action. Breast milk is crucial for the baby's nutrition and immune support once enteral feedings begin. This action empowers the parents to actively contribute to their baby's care and prepares for future needs. .
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