Difficulty: Medium
Average Score: 92%
Simulated
Passage / Scenario
Medical History: Gravida 1 Para 1, 41 weeks of gestation, Cesarean birth following prolonged rupture of membranes and cephalopelvic disproportion. Vital Signs: Temperature 38.4┬░ C (101.1┬░ F), Blood pressure 118/72 mm Hg, Heart rate 108/min, Respiratory rate 20/min. Breasts: Client reports their breasts are starting to feel firmer and heavier. Denies nipple discomfort. Client is bottle-feeding their newborn. Uterus: Boggy and tender to palpation. Fundus at the umbilicus. Lochia: Moderate amount of dark brown, foul-smelling discharge. Bladder: Client reports frequent voiding without difficulty. Lower extremities: Bilateral edema of lower extremities noted without pain, warmth, or tenderness. Nurses' Notes: Client reports general malaise, chills, and a decreased appetite.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to evaluate the client's progress. Condition Most Likely: ___ Actions to Take: ___ Parameters to Monitor: ___
Rationale
The client has fever (38.4┬░C/101.1┬░F), tachycardia (HR 108/min), uterine tenderness, and foul-smelling lochia, all of which indicate postpartum uterine infection (endometritis). Administering broad-spectrum antibiotics treats the infection, and oxytocic medication promotes uterine contraction to reduce bacterial growth. Monitoring temperature and lochia amount/odor evaluates treatment progress.