Nokea
The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? Select all that apply.
- A. Oral temperature of 102.2°F (39°C)
- B. Telangiectasis on the neck and chest
- C. Mild abdominal tenderness with palpation
- D. Lochial discharge that is foul smelling
- E. White blood cell count of 16,500 cells/mm3
Correct Answer: A,D
Rationale: A temperature of 100.4°F (38°C) or higher after 24 hours postpartum is associated with a puerperal infection. Telangiectasis is red, slightly raised vascular “spiders” that may appear during pregnancy over the neck, thorax, face, or arms and remain or fade during the postpartum period. It is not indicative of an infection. Slight abdominal tenderness with palpation is a normal postpartum finding. Malodorous lochia is a common sign of a puerperal infection. A WBC count of 16,500 is normal for the postpartum client; labor produces a mild pro-inflammatory state.
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Which expected outcome should the nurse include based on the client's eating habits?
- A. The client will eat three balanced meals and two snacks daily while pregnant.
- B. The client will gain a total of 50 pounds during the pregnancy.
- C. The client will take two prenatal vitamins daily.
- D. The client will report eating about 2,000 calories per day.
Correct Answer: A
Rationale: Eating three balanced meals and two snacks daily addresses the client's poor eating habits and supports nutritional needs.
Which client is at highest risk for ectopic pregnancy?
- A. A client with a history of pelvic inflammatory disease
- B. A client with a normal ultrasound
- C. A client with regular menstrual cycles
- D. A client taking prenatal vitamins
Correct Answer: A
Rationale: Pelvic inflammatory disease increases the risk of ectopic pregnancy by causing tubal scarring, which can impede embryo passage.
The client with mastitis asks the nurse if she should stop breastfeeding because she has developed a breast infection. Which response by the nurse is best?
- A. “Continuing to breastfeed will decrease the duration of your symptoms.”
- B. “Breastfeeding should only be continued if your symptoms decrease.”
- C. “Stop feeding for 24 hours until antibiotic therapy begins to take effect.”
- D. “It is best to stop breastfeeding because the infant may become infected.”
Correct Answer: A
Rationale: Continuing to breastfeed is recommended when the client has mastitis. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased. Continuing to breastfeed will decrease the symptoms of mastitis; there is no need to wait for symptoms to decrease. Usually an oral penicillinase-resistant penicillin or cephalosporin that is safe for the infant while breastfeeding is given to treat mastitis. There is no need for the client to stop breastfeeding for 24 hours. The infant’s nose and throat are the most common sources of the organism that causes mastitis. Infants of women with mastitis generally remain well; thus, concern that the mother will infect the infant if she continues breastfeeding is unwarranted.
Using Naegele's Rule, the nurse can assume the client's expected delivery date to be approximately which date?
- A. 13-Nov
- B. 23-Nov
- C. 3-Dec
- D. 20-Dec
Correct Answer: C
Rationale: Naegele's Rule: Subtract 3 months from the first day of the last menstrual period (March 13) and add 7 days, resulting in December 3.
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.