The nurse should suspect puerperal infection when a client exhibits which of the following?

Correct Answer: D

Rationale: In the postpartum period, it is essential for nurses to be vigilant for signs of puerperal infection, as prompt recognition and treatment are crucial. The correct answer is D) Malodorous lochial discharge. This symptom is indicative of a possible uterine infection, as foul-smelling lochia can be a sign of endometritis, a common puerperal infection. Option A) Temperature of 100.2°F could be seen as a normal finding in the immediate postpartum period due to physiological changes, such as milk coming in, and may not necessarily indicate infection. Option B) White blood cell count of 14,500 cells/mm3 is slightly elevated but not specific to puerperal infection, as WBC count can be elevated post-delivery. Option C) Diaphoresis during the night is a common postpartum symptom due to hormonal shifts and is not a specific indicator of puerperal infection. It is important for nurses to understand the normal postpartum changes to differentiate them from signs of infection to provide appropriate care and intervention for the mother. Educationally, nurses need to be taught to assess and differentiate between normal postpartum occurrences and signs of complications like puerperal infection. Understanding the significance of malodorous lochia as a potential indicator of infection can lead to early intervention, preventing the escalation of complications and promoting the well-being of the postpartum woman.

Correct Answer: C

Rationale: The correct answer is C: "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." Explanation: Breastfeeding provides the baby with essential antibodies and nutrients that can help protect against illnesses. By continuing to breastfeed, the mother passes on her immune system's defense mechanisms to the baby, reducing the chances of the baby getting sick. Breast milk is a complete source of nutrition and immune protection for infants, making it the best option for their overall health, especially when the mother is sick. Option A is incorrect because while boiling water is important for formula preparation to prevent infections like diarrhea, it is not necessary in this scenario. Option B is incorrect because while pumping breast milk is essential for maintaining milk supply, it is not the best solution in this situation where breastfeeding is still the optimal choice. Option D is unnecessary and may cause unnecessary alarm as wearing a surgical mask is not typically recommended unless the mother is showing symptoms of a contagious illness like the flu. In an educational context, it is crucial to emphasize the importance of breastfeeding for both the baby's and the mother's health. Educating mothers about the benefits of breastfeeding, especially during times of illness, can help them make informed decisions that promote the well-being of their child. It is also essential to provide support and resources to help mothers continue breastfeeding successfully, even during challenging times.

Correct Answer: C

Rationale: In caring for a postoperative cesarean client who is obese and insulin-dependent, it is crucial for the nurse to carefully monitor for wound dehiscence. Rationale for the correct answer (Option C): Wound dehiscence is a serious complication in obese and diabetic patients due to impaired wound healing, increased risk of infection, and compromised tissue integrity. The combination of obesity and diabetes further exacerbates these risks, making wound dehiscence a significant concern that can lead to severe complications if not promptly detected and managed. Rationale for incorrect options: A) Failed lactogenesis: While important for postpartum care, failed lactogenesis is not typically directly related to obesity or diabetes in the immediate postoperative period following a cesarean section. B) Dysfunctional parenting: This is not a physiological complication related to the client's medical conditions or postoperative status. D) Projectile vomiting: While vomiting can be a concern postoperatively, projectile vomiting is not specifically associated with obesity or diabetes in this context. Educational context: Understanding the specific risks and complications associated with obesity and diabetes in the postpartum period is essential for nurses caring for these patients. Monitoring for wound dehiscence, in particular, is critical due to the increased vulnerability of these patients to wound-related complications. Early recognition and intervention can help prevent further issues and promote optimal healing outcomes for the client.

Correct Answer: C

Rationale: In the immediate postpartum period, hormonal changes can affect a woman's vital signs. The correct interpretation of the findings in this case is option C: "Respirations are too low, a sign of medication toxicity." Postoperative cesarean clients often receive pain medications, which can depress the respiratory drive and lead to hypoventilation. This is supported by the normal temperature, pulse, and blood pressure readings in this scenario. Option A (Temperature is elevated, a sign of infection) is incorrect because the temperature of 100.0°F is within normal limits for the postpartum period and can be attributed to the normal inflammatory response after surgery. Option B (Pulse is too low, a sign of vagal pathology) is incorrect as a pulse of 68 beats per minute is within the expected range for a postoperative client and does not indicate vagal pathology. Option D (Blood pressure is elevated, a sign of preeclampsia) is incorrect as the blood pressure reading of 130/80 is also within normal limits for the postpartum period and does not suggest preeclampsia. Educationally, it is vital for nurses to understand the expected physiological changes in the postpartum period and how to differentiate normal variations from potential complications. Monitoring vital signs and recognizing signs of medication toxicity are crucial skills for postoperative care to ensure the safety and well-being of the mother.

Correct Answer: C

Rationale: In the context of postpartum hormonal changes, it is crucial for nurses to be vigilant for signs of deep vein thrombosis (DVT) due to the increased risk during this period. Option C is the correct choice because swelling, redness, and warmth in one calf are classic signs of DVT. This combination suggests a possible blood clot in the deep veins of the leg, requiring immediate medical attention to prevent serious complications like pulmonary embolism. Option A is incorrect because numbness in the toes and heel is more indicative of nerve-related issues rather than DVT. Option B is incorrect as cramping pain in the calf that is relieved by dorsiflexion is a sign of muscle cramps or strain, not DVT. Option D is also incorrect as spider-like and purple veins in the ankle are more likely due to superficial venous issues like varicose veins, not DVT. Educationally, understanding the signs and symptoms of DVT is essential for nurses caring for postpartum women to ensure timely detection and intervention. By emphasizing the importance of recognizing these specific manifestations, nurses can play a crucial role in preventing life-threatening complications associated with DVT in this vulnerable population.