165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)

Rationale for Correct Choices:

• Intravenous antibiotic: The client exhibits signs of postpartum infection, most consistent with endometritis—elevated WBC count, low-grade fever, uterine tenderness, foul-smelling lochia, and a history of prolonged rupture of membranes and cesarean delivery. IV antibiotics are the first-line treatment to control uterine infection and prevent sepsis.
• Increase in daily fluid intake: Maintaining adequate hydration is essential to support tissue perfusion and aid in the clearance of infection. Fever and elevated WBCs increase metabolic demands, so increased fluid intake can help mitigate dehydration and support antibiotic therapy.

Rationale for Incorrect Choices:

• Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage, typically used after trauma or suspected placental abruption. It is not indicated in cases of suspected postpartum infection.
• Intrauterine tamponade balloon: This intervention is used for managing postpartum hemorrhage due to uterine atony or trauma, not infection. The client’s bleeding is moderate and not indicative of uncontrolled hemorrhage.
• Tocolytic medication: Tocolytics are used to suppress premature labor and have no role in postpartum care, especially in the presence of infection, where uterine relaxation could worsen outcomes.

A. “Does the doctor know that you are eating that?”: Questioning the client’s food choice may come across as judgmental and does not address the client’s immediate request or provide support.
B. “The hospital food is more nutritious for you.”: Comparing foods in this way may discourage the client and does not acknowledge cultural preferences or the client’s autonomy in food choices.
C. “Why are you eating seaweed soup?”: Asking “why” can seem confrontational and may make the client feel defensive instead of supported during the postpartum period.
D. "Of course, I will heat that up for you.”: This response respects the client’s autonomy, supports cultural preferences, and provides comfort, which helps build trust and rapport in the nurse-client relationship.