A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?

Cleanse the perineum with 0.9% sodium chloride after bowel movements

Obtain serial blood cultures.

Insert and maintain an indwelling urinary catheter.

Encourage the use of a sitz bath twice a day,

Answer and Explanation

The Correct Answer is B

Rationale:

A. Cleanse the perineum with 0.9% sodium chloride after bowel movements: While perineal hygiene is important postpartum, cleansing with normal saline is more routine care and does not specifically target endometritis management.

B. Obtain serial blood cultures: Endometritis is a uterine infection that can lead to bacteremia or sepsis. Serial blood cultures help identify the causative organism and guide antibiotic therapy.

C. Insert and maintain an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not routinely used unless there is urinary retention or other specific indications.

D. Encourage the use of a sitz bath twice a day: Sitz baths promote perineal comfort and hygiene but do not directly treat uterine infections like endometritis. They may be recommended for perineal pain but are not primary treatment for endometritis.

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Correct Answer is B

Explanation

Rationale:

A. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is an appropriate and necessary exchange of client information for continuity of care. It supports safe, effective handoff communication between nurses involved in the client’s treatment.

B. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: This violates the Health Insurance Portability and Accountability Act (HIPAA) by sharing protected health information with someone not directly involved in the client’s care, regardless of location or setting.

C. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is an expected and proper part of nursing responsibilities. Accurate and timely documentation in the EMR is essential for effective communication and patient safety.

D. A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable health information is included, printing such materials for professional reference or education is acceptable and does not violate confidentiality rules.

A. Case manager B. Primary care provider C. Nutritionist D. Pediatric nurse practitioner

Correct Answer is A

Explanation

Rationale:

A. Case manager: Case managers coordinate resources and support services for clients, including assistance with financial concerns and access to programs that provide free or low-cost baby formula. They are the best resource to help the client navigate community aid and social services.

B. Primary care provider: While the primary care provider manages the client’s overall health, they are not typically responsible for connecting clients with financial assistance programs related to infant feeding.

C. Nutritionist: Nutritionists provide dietary advice and education but generally do not address financial barriers or resource allocation for obtaining formula.

D. Pediatric nurse practitioner: Pediatric nurse practitioners focus on the infant’s health and development and may provide feeding guidance, but addressing the client’s financial inability to pay for formula falls outside their primary role.

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A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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