If the client's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take?
a. Document the finding.
b. Tell the health care provider.
c. Begin antibiotic therapy immediately.
d. Have the laboratory draw blood for reanalysis.
ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. Because this is a normal finding, there is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated.
You might also like to view...
A 30-year-old woman who has given birth 12 hours prior is displaying signs and symptoms of disseminated intravascular coagulation (DIC)
The client's husband is confused as to why a disease of coagulation can result in bleeding. Which of the nurse's following statements best characterizes DIC? A) "So much clotting takes place that there are no available clotting components left, and bleeding ensues." B) "Massive clotting causes irritation, friction, and bleeding in the small blood vessels." C) "Excessive activation of clotting causes an overload of vital organs, resulting in bleeding." D) "The same hormones and bacteria that cause clotting also cause bleeding."
The nurse is checking placement of a nasogastric (NG) tube that has been in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate?
A) The tube is in the pleural space. B) The tube is the intestine. C) The tube is in the stomach. D) The tube is in the esophagus.
When analyzing the feelings of others, or the nurse's own feelings, the nurse is:
A) Conducting a self-assessment. B) Engaging in introspection. C) Testing boundaries. D) Conducting an affective analysis.
In the nature versus nurture controversy about human development, the nature view sees development as mainly influenced by which of the following factors?
a. genetic c. culture b. environmental d. chance