Difficulty: Medium
Average Score: 89%
Simulated
Passage / Scenario
A nurse is caring for a postpartum client who gave birth 3 days ago.Exhibit 1
Vital Signs
Temperature 38.4┬░ C (101.1┬░ F)
Heart rate 108/min
Respiratory rate 20/min
Blood pressure 118/72 mm Hg
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 assess the client's progress.
Rationale
Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.