What is the priority nursing intervention for a client who has just given birth to her fifth child

Pediatric Nurse Exam Sample Questions

These sample questions apply to all exams taken on or after October 25, 2014.

The following sample questions are similar to those on the examination but do not represent the full range of content or levels of difficulty. The answers to the sample questions are provided after the last question. Please note: Taking these or any sample question(s) is not a requirement to sit for an actual certification examination. Completion of these or any other sample question(s) does not imply eligibility for certification or successful performance on any certification examination.

To respond to the sample questions, first enter your first and last names in the boxes below (this information will not be recorded; it is strictly for purposes of identifying your results). Then click the button corresponding to the best answer for each question. When you are finished, click the "Evaluate" button at the bottom of the page. A new browser window will open, displaying your results, which you may print, if you wish.

This practice exam is not timed, and you may take it as many times as you wish. Good luck!

Puerperal infection is a reproductive tract infection occurring within 28 days following childbirth or abortion. It is one of the major causes of maternal death (ranking second behind postpartum hemorrhage). It includes localized infectious processes and more progressive processes that may result in endometritis (inflammation of endometrium), peritonitis, or parametritis/pelvic cellulitis (infection of connective tissue of broad ligament and possibly connective tissue of all pelvic structures).

Theoretically, the uterus is sterile during pregnancy and up until the membranes rupture. After rupture, pathogens can begin to invade; the risk of infection grows even greater if tissue edema and trauma are present. Organisms commonly cultured post partially include group B streptococci, staphylococci, and aerobic gram-negative bacilli such as Escherichia coli.

Tissue trauma during labor, the open wound of the placental insertion site, surgical incisions, cracks in the nipples of the breasts, and the increased pH of the vagina after birth are all risk factors for the postpartum woman.

Prevention measures of puerperal infection should be taken before pregnancy and during pregnancy, delivery, and puerperium. During puerperium, it is recommended that puerperae get enough sleep, strengthen nutrition reasonably, and improve the body’s immunity, the health management is strengthened, and prevention measures be actively taken for puerperae with high-risk factors, thereby improving the prognosis of clients and reducing the incidence of puerperal infection (Song et al., 2019).

The nursing management of clients diagnosed with puerperal infection includes preventing the spread of infection, promoting healing, and improving the attachment/bonding of parent and infant.

Here are five nursing care plans and nursing diagnoses for puerperal and postpartum infections:

Risk For Infection

During the delivery process, changes in the physiological structure of pregnant women, hemorrhage, delivery injury, etc., lead to the decline in the body’s immunity, resulting in puerperal infection under some risk factors. Birth canal injury is caused due to fetal delivery via the reproductive tract during the puerperium, and the body’s immunity of pregnant women significantly declines during the puerperium. As a result, pathogenic microorganisms invade the human body, leading to infection, septicopyemia, and threatening maternal life (Song et al., 2019).

Nursing Diagnosis

• Risk for Infection

Risk Factors

• Presence of infection, broken skin, and/or traumatized tissues
• High vascularity of the involved area
• Invasive procedures and/or increased environmental exposure
• Chronic disease (e.g., diabetes), anemia, malnutrition
• Immunosuppression and/or untoward effect of medication (e.g., opportunistic/secondary infections)

Possibly evidenced by

• [Not applicable]

Desired Outcomes

• The client will verbalize understanding of individual causative risk factors.
• The client will initiate behaviors to limit the spread of infection as appropriate and reduce the risk of complications.
• The client will achieve timely healing, free of additional complications.

Nursing Assessments and Rationales

1. Review prenatal, intrapartal, and postpartal record.
A review of the client’s previous health records identifies factors that place the client in a high-risk category for the development/spread of postpartal infection. Analyses of risk factors for puerperal infection showed that the body mass index >25, placenta previa, placenta accreta, postpartum hemorrhage, premature rupture of membranes, gestational diabetes, and anemia during pregnancy were relevant and independent risk factors for puerperal infection (Song et al., 2019).

2. Monitor temperature, pulse, and respiration. Note the presence of chills or reports of anorexia or malaise.
Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. The fever is most often caused by endometritis, an inflammation of the inner lining of the uterus. Puerperal fever is a temperature of 38℃ (100.4℉) or higher after the first 24 hours and for at least two days during the first ten days after birth. A pulse rate that is higher than expected and an elevated temperature often occur when the client has an infection.

3. Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge, and approximation [REEDA scale]).
This allows early identification and treatment; promotes resolution of infection. The assessment of any cesarean birth wound or episiotomy wound using the REEDA criteria or hardening of the operative area should be promptly reported and documented.

4. Note subinvolution of uterus, extreme uterine tenderness, and lochia.
The client’s uterus usually is not well contracted and is painful to touch. She may feel strong afterpains. Lochia usually is dark brown and has a foul odor. It may be increased in amount because of poor uterine involution, but if the infection is accompanied by high fever, lochia may, in contrast, be scant or absent.

5. Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day—note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea.
Increased intake replaces losses and enhances circulating volume, preventing dehydration and reducing fever. Slight temperature elevations with no other signs of infection often occur during the first 24 hours because of dehydration.

6. Investigate reports of leg or chest pain. Note pallor, swelling, or stiffness of the lower extremity.
These signs and symptoms are suggestive of septic thrombus formation. Note: Embolic sequelae, especially pulmonary embolism, may be an initial indicator of thrombophlebitis. The levels of fibrinogen and other clotting factors normally increase during pregnancy. In contrast, levels of clot-dissolving factors (plasminogen activator and antithrombin III) are normally decreased, resulting in a state of hypercoagulability.

Nursing Interventions and Rationales

1. Demonstrate and maintain a strict hand-washing policy for staff, clients, and visitors.
Proper hand hygiene is the primary method to prevent the spread of infectious organisms. The client should be taught to wash her hands before and after performing self-care that may involve contact with secretions.

2. Ensure the proper handling of sterile instruments and the proper use of personal protective equipment (PPE).
To help prevent infection, any articles such as gloves or instruments that are introduced into the birth canal during labor, birth, and the postpartum period should be sterile. In addition, adherence to standard infection precautions is essential. Gloves should be worn when contacting blood, body fluid, or other potentially infectious materials.

3. Demonstrate correct perineal cleaning after voiding and defecation and frequent changing of peripads.
Changing pad removes moist medium that favors bacterial growth. Be certain to instruct a postpartal client in proper perineal care, including wiping from front to back so that she doesn’t bring E. coli organisms forward from the rectum. When giving perineal care, the nurse must wash hands and wear gloves. Each postpartal client should have their supplies and should not share them to prevent the transfer of pathogens from one client to another.

4. Demonstrate proper fundal massage. Review the importance and timing of the procedure.
Fundal massage may enhance uterine contractility. It may promote involution and passage of any retained placental fragments. Subinvolution may result from a small retained placental fragment, mild endometritis, or an accompanying problem such as uterine myoma that interferes with complete contraction.

5. Encourage semi-Fowler’s position.
Sitting in a semi-Fowler’s position or walking encourages lochia drainage by gravity and helps prevent the pooling of infected secretions.

6. Encourage the client to consume a high-protein and vitamin C-rich diet.
Ultimately, the client’s body must overcome infection and heal any wound. Nutrition is an essential component of her body’s defenses. The nurse, and sometimes a dietitian, should teach her about foods that are high in protein (meats, cheese, milk, legumes) and vitamin C )citrus fruits and juices, strawberries, and cantaloupe) because these nutrients are especially important for healing.

7. Promote early ambulation, balanced with adequate rest—advance activity as appropriate.
The nurse should explore ways to help the client get enough rest. This may increase circulation, promote clearing respiratory secretions and lochial drainage, and enhance healing and general well-being. Ambulation and limiting the time the client remains in obstetric stirrups encourages circulation to the lower extremities, promotes venous return, and decreases clot formation. Help the client select her activities to exercise other body parts or stimulate her mind.

8. Recommend that the breastfeeding mother periodically check the infant’s mouth for the presence of white patches.
Oral thrush in the newborn is a common side effect of maternal antibiotic therapy. Be certain the breastfeeding client is not prescribed antibiotics incompatible with breastfeeding. Alert them to observe for problems in their infant, such as white plaques or thrush in their mouth that can occur when a portion of maternal antibiotic passes into breast milk and causes an overgrowth of fungal organisms in the infant.

9. Encourage client/couple to prioritize postdischarge responsibilities (e.g., homemaking tasks, child care)
The client will require additional rest to facilitate recuperation/healing. Household duties need to be reassigned or delayed as appropriate. Women discharged from the hospital may be cared for at home on bed rest.

10. Instruct proper medication use (e.g., with or without meals, take the entire course of antibiotic, as prescribed).
Oral antibiotics may be continued after discharge. Failure to complete medication may lead to relapse. If the client is continuing drug therapy at home, stress that she must take the full course to prevent the infection from recurring.

11. Discuss the importance of pelvic rest as appropriate (avoidance of douching, tampons, and intercourse).
This promotes healing and reduces the risk of reinfection. Bacteria may gain access to the vagina and uterus through these practices and lead to endometritis or peritonitis. Douching results in changes in the vaginal flora and predisposes the client to develop pelvic inflammatory disease (PID), bacterial vaginosis, and ectopic pregnancies. However, many women practice regular douching, believing it is cleansing. The nurse can play an important role in educating the woman to prevent PID.

12. Monitor laboratory studies, as indicated:
Identifies infectious process/causative organism and appropriate antimicrobial agents.

• 12.1. Culture(s)/sensitivity; CBC, WBC count, differential, and ESR.
  This aids in tracking the resolution of the infectious or inflammatory processes. Identifies the degree of blood loss and determines the presence of anemia. WBCs are normally elevated during the early postpartum period to about 20,000 to 30,000 cells/mm³, limiting the blood count’s usefulness in identifying infection. Leukocyte counts in the upper limits are more likely to be associated with infection than lower counts.

• 12.2. Partial thromboplastin time/prothrombin time (PTT/PT), clotting times.
  This help identifies alterations in clotting associated with the development of emboli and aid in determining the effectiveness of anticoagulation therapy. A blood coagulation study will be necessary to establish a baseline value followed by sequential tests to determine the effectiveness of heparin therapy, as appropriate.

• 12.3. Renal/hepatic function studies.
  Hepatic insufficiency and decreased renal function may develop, altering drug half-life and increasing toxicity risks. Sepsis, including puerperal sepsis and pyelonephritis, are common causes of pre-renal acute kidney injury. In addition, sepsis is increasingly recognized to have direct nephrotoxic effects (Hall & Conti-Ramsden, 2019).

13. Encourage the application of moist heat in the form of sitz baths, compresses,  and dry heat in the form of perineal lights for 15 min 2–4 times daily.
Water promotes cleansing. Heat dilates perineal blood vessels, increasing localized blood flow and promoting healing. Cover wet, warm dressings with a plastic pad to hold heat and moisture. In addition, position a commercial pad with circulating heating coils or chemical hot packs over the plastic to ensure soaks stay warm.

14. Provide supplemental oxygen when necessary.
Oxygen promotes healing and tissue regeneration, especially in anemia; it may enhance oxygenation when pulmonary emboli are present. When there is a pulmonary embolus, the client needs oxygen administered immediately and is at high risk for cardiopulmonary arrest. The blood clot may block blood flow to the lungs and return to the heart.

15. Demonstrate perineal application of antibiotic creams, as appropriate.
Topical antibiotics eradicate local infectious organisms, reducing the risk of spreading infection. Infections of the perineum usually remain localized. The client may or may not have an elevated temperature depending on the systemic effect and spread of the infection.

16. Administer medications as indicated:

• 16.1. Antibiotics, initially broad-spectrum, then organism-specific, as indicated by results of cultures/sensitivity.
  Antibiotics combat pathogenic organisms, helping prevent infection from spreading to surrounding tissues and the bloodstream. Note: Parenteral route is preferred for parametritis, peritonitis, and, on occasion, endometritis. Frequently used antibiotics include ampicillin, gentamicin, and third-generation cephalosporins such as cefixime.
• 16.2. Oxytocics, such as Pitocin and methylergonovine maleate (Methergine).
  Oxytocics promote myometrial contractility to retard the spread of bacteria through the uterine walls and aid in the expulsion of clots and retained placental fragments.
• 16.3. Anticoagulants (e.g., heparin).
  In the presence of pelvic thrombophlebitis, anticoagulants prevent or reduce additional thrombi formation and limit the spread of septic emboli. The client undergoing anticoagulant therapy at home should be taught how to give herself the drug and signs of excess anticoagulation.

17. Administer whole blood/packed RBCs, if needed.
These blood products replace blood losses and increase oxygen-carrying capacity in the presence of severe anemia or hemorrhage. Extensive blood loss is one of the precursors of postpartum infection because of the general debilitation that results.

18. Arrange for transfer to intensive care setting as appropriate.
It may be necessary for clients with severe infection (e.g., peritonitis, sepsis) or pulmonary emboli to provide appropriate care leading to optimal recovery. Puerperal infection is always potentially serious because, although it usually begins only as a local infection, it has the potential to spread to the peritoneum (peritonitis) or the circulatory system (septicemia) conditions that can be fatal in a client whose body is already stressed from childbirth.

19. Assist with procedures, such as incision and drainage (I&D) or D&C, as necessary.
Draining the infected area and possibly inserting iodoform gauze packing promotes healing and reduces the risk of rupturing the peritoneal cavity. D&C may be needed to remove retained products of conception and/or placental fragments. In some instances, placenta accreta is so deeply attached that balloon occlusion and embolization of the internal iliac arteries may be necessary to minimize blood loss. In others, a hysterectomy must be performed.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Recommended journals, books, and other interesting materials to help you learn more about puerperal and postpartum infections nursing care plans and nursing diagnosis:

Which assessment finding 1 hour after birth should be reported to the health care provider?

Which nonpharmacologic measures are appropriate to reduce postpartum discomfort?

For which reason is a postpartum client encouraged to walk?

Which of the following would you emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?