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 nurse and provider estimate the blood loss at delivery to be 400 mL in the measuring drape; now when doing the initial perineal care, the nurse finds a large amount of blood underneath the patient. What action reflects safe and accurate nursing care?
- A. Estimate the amount of blood loss from the sheet and client clothing, and notify the physician.
- B. Encourage the mother to report any additional bleeding or clots.
- C. Draw the ordered hematocrit and notify the provider if the result is less than 28.
- D. Weigh the blood-soaked linens and notify the provider of the additional blood loss.
Correct Answer: D
Rationale: Weighing the blood-soaked linens is a safe and accurate method to estimate blood loss.
The nurse educates the person with a newborn in the NICU. What guidance does the nurse provide?
- A. Breast milk is not good for a premature baby.
- B. Premature babies breast-feed easily.
- C. Skin-to-skin contact helps both baby and breast-feeding person.
- D. A bottle is recommended for all feedings.
Correct Answer: C
Rationale: The correct answer is C because skin-to-skin contact promotes bonding, regulates the baby's temperature, and encourages breastfeeding. This guidance is crucial for newborns in the NICU to establish a strong connection with their caregiver and support breastfeeding. Choice A is incorrect as breast milk is highly beneficial for premature babies. Choice B is incorrect because premature babies may struggle with breastfeeding due to their developmental stage. Choice D is incorrect as bottles are not recommended for all feedings, especially for premature infants who may have difficulty latching and feeding effectively.
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see?
- A. Diaphoresis.
- B. Lochia alba.
- C. Cracked nipples.
- D. Hypertension.
Correct Answer: B
Rationale: By the second week postpartum, lochia typically transitions to alba (white or yellowish discharge).
What is characteristic of a late (secondary) PPH?
- A. occurs within the first 24 hours
- B. is caused by subinvolution of the uterus
- C. does not occur after cesarean births
- D. cannot be treated with Methergine
Correct Answer: B
Rationale: Late (secondary) postpartum hemorrhage is typically caused by subinvolution of the uterus and may occur after the first 24 hours.
The nurse notices the uterus is boggy and the bladder is full. What intervention should the nurse perform next?
- A. Call for help.
- B. Start IV bolus.
- C. Get the person out of bed to walk to restroom.
- D. Massage the fundus and assess the lochia.
Correct Answer: D
Rationale: A boggy uterus and full bladder may indicate uterine atonyand fundal massage is the first intervention to promote uterine contraction.