Take full exam for free

A nurse is caring for a client who is 3 days postpartum in the postpartum unit.

History and Physical: A 30-year-old female client had a vaginal birth 3 days ago with prolonged rupture of membranes. Internal fetal monitoring was used during labor. The client has been experiencing fever, chills, and abdominal pain. She has a history of gestational diabetes and hypertension.

Nurses Notes: The client reports feeling weak and fatigued. She has been having difficulty breastfeeding and feels engorged. The lochia is malodorous and heavy. She complains of a headache and dizziness. The client has been crying frequently and expresses feeling overwhelmed. She also mentions that she has not been able to sleep well since delivery.

Vital Signs:

Temperature: 38.5°C (101.3°F)

Pulse: 110 bpm
Respiratory rate: 24 breaths per minute

Blood pressure: 140/90 mmHg

Oxygen saturation: 98% on room air

Physical Examination Results:

The client appears pale and diaphoretic. Her breasts are tender and engorged with signs of erythema. The abdomen is soft but tender to palpation, especially in the lower quadrants. The fundus is boggy and located above the umbilicus. Lochia is heavy and malodorous. There is mild pedal edema noted in both lower extremities.

Querry:A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client.)

Obtain a prescription for a broad-spectrum antibiotic.

Initiate airborne isolation precautions.

Place the client on strict bedrest.

Instruct the client to stop breastfeeding.

Answer and Explanation

The Correct Answer is A

A. Obtain a prescription for a broad-spectrum antibiotic.

The client's fever (38.5°C), chills, abdominal pain, malodorous lochia, and tender fundus suggest a potential postpartum infection, such as endometritis. Administering a broad-spectrum antibiotic is necessary to treat the infection. Given the clinical scenario, the nurse should prioritize addressing the client's symptoms and signs that suggest infection and support her well-being postpartum. Here's a breakdown of the appropriate actions:

B. Initiate airborne isolation precautions.

Not necessary in this case. The client's symptoms and signs do not suggest an airborne infectious disease.

C. Place the client on strict bedrest.

This is not necessary. While rest is important, strict bedrest may not be required and could increase the risk of other complications, such as deep vein thrombosis (DVT).

D. Instruct the client to stop breastfeeding.

Not necessary unless there is a specific contraindication. Instead, the nurse can provide support and advice on managing engorgement and breastfeeding difficulties.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Manifestations of shock might not appear until a client loses 20% of their blood volume. B. Hemorrhagic shock will cause an increase in a client's serum pH. C. The most accurate indication of organ perfusion is a client's urine output. D. An infusion of 1 mL of lactated Ringers is given for each 1 mL of blood loss.

Correct Answer is A

Explanation

Choice A rationale

Manifestations of shock might not appear until a client loses 20% of their blood volume. This is because the body compensates for blood loss by increasing heart rate and

vasoconstriction, maintaining blood pressure until a significant amount of blood is lost.

Choice B rationale

Hemorrhagic shock will cause a decrease, not an increase, in a client's serum pH due to the accumulation of lactic acid from anaerobic metabolism, leading to metabolic acidosis.

Choice C rationale

The most accurate indication of organ perfusion is a client's urine output. Adequate urine output reflects sufficient renal blood flow and overall perfusion, making it a reliable indicator

of organ perfusion.

Choice D rationale

An infusion of 1 mL of lactated Ringers for each 1 mL of blood loss is not accurate. The typical fluid replacement ratio is 3:, meaning 3 mL of crystalloid solution (like lactated Ringers) is given for each 1 mL of blood loss to account for fluid distribution in the body.

A. It is important to gain 2 pounds per week throughout the rest of your pregnancy. B. You can cause problems for your baby if you try to diet while pregnant. C. It would be helpful for us to meet with the dietitian to see how they can help you meet and assess your nutritional needs. D. You should eat an additional 700 calories per day while you are pregnant

Correct Answer is C

Explanation

Choice A rationale

Gaining 2 pounds per week throughout the rest of pregnancy is excessive and not recommended. Normal weight gain is approximately 1 pound per week in the second and third trimesters.

Choice B rationale

Dieting during pregnancy can lead to inadequate nutrient intake for both the mother and the developing fetus. It is essential to focus on a balanced diet rather than trying to lose weight.

Choice C rationale

Meeting with a dietitian can help the client assess their nutritional needs and develop a healthy eating plan to support their pregnancy, ensuring both maternal and fetal health.

Choice D rationale

Eating an additional 700 calories per day is too high. Generally, an additional 300-500 calories per day is recommended during the second and third trimesters to support pregnancy.

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is C

Explanation

Quick Links

Resources

Free Nursing Test Bank

A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

Correct Answer is A

Explanation

A nurse is caring for an adolescent client who is at 24 weeks of gestation. The client's prepregnancy weight was within the recommended range for their height and they have gained 2.7 kg (6 lb) during the pregnancy. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?

A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?

A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?

A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take?

A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect?

A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing a 1-hour-old newborn. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?

Quick Links

Resources