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More questions ( 20 Questions)
A nurse is assessing a postpartum client for signs of infection.
Which of the following should the nurse report immediately? A) Lochia with clots.
Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots. However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection
Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding. A soft or boggy fundus can be a sign of infection or hemorrhage.
Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside. However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Breast tenderness is wrong because some
Temperature greater than 38°C for more than 48 hours. This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention. A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours. This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention. A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots. However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding. A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside. However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some