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    Rn Hesi Pediatric And Women Health Proctored Exam
    Select All That Apply

    Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.

    Explanation & Rationale

    A. Rupture of membranes for 16 hours: Prolonged rupture of membranes increases the risk of bacterial invasion into the uterus, predisposing the client to postpartum infection such as endometritis, which aligns with her fever and foul-smelling lochia. B. Normal spontaneous vaginal birth: A normal vaginal delivery does not directly explain the client’s current fever, chills, and localized breast tenderness. It is a typical event in childbirth and not a causative factor of her acute symptoms. C. Breastfeeding 7 to 8 times a day for 10 minutes: This feeding pattern is normal for a breastfeeding mother. Although frequent nursing helps maintain milk flow, it does not explain the presence of systemic infection signs. D. Discharge hemoglobin of 9.2 g/dL (92 g/L): This value indicates mild postpartum anemia, which can cause fatigue or dizziness but does not cause fever, breast redness, or foul-smelling lochia. E. Current vital signs: Elevated temperature (101.2°F) and tachycardia (105 bpm) are hallmark indicators of infection. These findings, combined with chills and breast tenderness, point toward either mastitis or endometritis. F. Shopping yesterday for 5 hours: Leaving the baby for several hours may have contributed to milk stasis, increasing mastitis risk, The fever and localized breast symptoms strongly suggest the onset of mastitis, often triggered by incomplete breast emptying and engorgement G. Foul-smelling lochia rubra: Foul odor in lochia suggests uterine infection (endometritis). Combined with fever and uterine tenderness, it strongly indicates that infection is contributing to the client’s current symptoms.

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