A nurse is assisting with providing care for a 23-year-old female client who is in labor in the labor and delivery unit.

Exhibits

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

For each potential intervention, specify if the intervention is anticipated, nonessential, or contraindicated for the client.

Choice A rationale

Disabling the driver-side airbags is not advisable as airbags provide crucial protection in the event of a collision. Proper seating position is a safer alternative.

Choice B rationale

Moving the seat as far away as possible from the steering wheel reduces the risk of injury from airbag deployment and allows ample space for the growing abdomen, providing better safety for both mother and baby.

Choice C rationale

Wearing the lap belt high across the abdomen is incorrect and dangerous as it can cause injury to the fetus. The belt should be low across the hips.

Choice D rationale

Placing the shoulder harness across the gravid uterus is incorrect. The harness should go between the breasts and to the side of the belly, not across it, to avoid compression injuries in the event of a crash.

Endometritis is indicated by a high temperature (38.4°C), elevated heart rate (108/min), foul-smelling lochia, and a tender boggy uterus. These are classic signs of infection post-cesarean birth, particularly following prolonged rupture of membranes, which increases infection risk. Administering broad-spectrum antibiotics targets the infection, while oxytocic medication helps manage uterine atony and promote uterine contraction to expel infected lochia.

Actions Explanation:

1. Administer broad-spectrum antibiotic medication: This addresses the underlying infection causing endometritis.
2. Monitor the administration of an oxytocic medication: Ensures uterine contraction, reducing uterine atony and helping clear infected materials.

Parameters to Monitor:

1. Temperature: Indicates the presence and resolution of infection.
2. Lochia amount and odor: Helps assess the severity of infection and effectiveness of treatment.

Other Conditions:

• B. Urinary tract infection (UTI): Less likely since the client denies urinary symptoms like burning or difficulty.
• C. Deep vein thrombosis (DVT): Bilateral lower extremity edema without pain, warmth, or tenderness doesn't align with unilateral swelling/pain typical of DVT.
• D. Engorgement: Not likely since the client is bottle-feeding and denies nipple discomfort; also, the lochia characteristics and boggy uterus point to infection.