Nokea
What is one of the initial signs and symptoms of puerperal infection in the postpartum client?
- A. Fatigue continuing for longer than 1 week
- B. Pain with voiding
- C. Profuse vaginal lochia with ambulation
- D. Temperature of 38° C (100.4° F) or higher on 2 successive days
Correct Answer: D
Rationale: The correct answer is D because a temperature of 38°C (100.4°F) or higher on 2 successive days is a key sign of puerperal infection. This is due to the body's response to infection. Fatigue (choice A) can be a symptom but is nonspecific. Pain with voiding (choice B) may indicate a urinary tract infection. Profuse vaginal lochia (choice C) may be normal postpartum.
You may also like to solve these questions
The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
- A. Flush the IV with normal saline to improve the flow rate.
- B. Put the IV antibiotic on a pump for more accurate infusion of the correct dose.
- C. Remove the IV, restart it in a new location, and complete the antibiotic administration.
- D. Allow the IV to continue to drip slowly since it is her last dose.
Correct Answer: C
Rationale: The IV site indicates phlebitis, and the appropriate action is to remove and restart the IV to avoid further complications.
Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate?
- A. Provide the woman with warm blankets.
- B. Put the woman in the Trendelenburg position.
- C. Notify the primary health care provider.
- D. Increase the intravenous infusion.
Correct Answer: A
Rationale: Shaking or chills immediately after delivery is common due to the drop in body temperature. Providing warm blankets helps alleviate this discomfort.
What is the most common reason for late postpartum hemorrhage (PPH)?
- A. Subinvolution of the uterus
- B. Defective vascularity of the decidua
- C. Cervical lacerations
- D. Coagulation disorders
Correct Answer: A
Rationale: Late postpartum hemorrhage (PPH), defined as occurring between 24 hours and up to 12 weeks after delivery, is most commonly due to subinvolution of the uterus. This occurs when the uterus fails to return to its normal pre-pregnancy size. Subinvolution can be caused by retained products of conception, uterine infection, uterine anomalies, or inadequate contraction of the uterine muscles. When the uterus does not contract effectively, it is unable to compress the blood vessels at the site of the placental attachment, leading to persistent bleeding. Subinvolution of the uterus is an important cause of late PPH and requires prompt intervention to prevent excessive blood loss and its associated complications.
What physiologic postpartum change occurs because the uterus shrinks in size, resulting in an increase in blood flow?
- A. Edema increases.
- B. Cardiac output increases.
- C. Temperature rises.
- D. Lochia increases.
Correct Answer: D
Rationale: As the uterus shrinks blood flow increases leading to the increased discharge of lochia.
A breastfeeding patient who is 5 weeks postpartum calls the clinic and reports that she is achy all over, has a temperature of 100.2°F, and has pain and tenderness in her right breast. What is the nurse’s best response?
- A. You need to come to the clinic to be evaluated, as your symptoms indicate a possible breast infection.
- B. You are having normal signs of engorgement with breastfeeding. More frequent breastfeeding will relieve your symptoms.
- C. Please stop breastfeeding until you can come to see the clinic provider, as you may have a breast infection.
- D. You may be experiencing sleep deprivation, which can make you feel achy and sore. Try to sleep when the newborn sleeps.
Correct Answer: A
Rationale: The correct answer is A because the patient's symptoms of achiness, fever, and pain in the breast are indicative of mastitis, a common breast infection in breastfeeding women. Prompt evaluation and treatment are necessary to prevent complications.
Choice B is incorrect as engorgement typically occurs in the first few days postpartum, not at 5 weeks.
Choice C is incorrect because stopping breastfeeding can worsen the infection and affect milk production.
Choice D is incorrect as the symptoms described are more likely due to an infection rather than just sleep deprivation.