A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes

1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

Choice A reason:

Discourage physical activity during the day is incorrect. Encouraging physical activity is generally beneficial for individuals with dementia. Regular exercise can improve mood, reduce agitation, and enhance overall health. However, the level and type of physical activity should be tailored to the individual's abilities and preferences.

Choice B reason

Use clothing with buttons and zippers is incorrect. Clothing with buttons and zippers can be challenging for individuals with dementia due to fine motor skill impairments and difficulty with dressing. It is often recommended to use clothing with simple closures, such as Velcro or elastic bands, to make dressing easier and more manageable for the individual.

Choice C reason:

Individuals with dementia may experience difficulties with communication, memory, and problem-solving, which can affect their ability to recognize and express the need to use the restroom. As a result, they may be at risk of urinary or bowel incontinence. To address this concern and promote the client's comfort and dignity, establishing a toileting schedule is essential. A consistent routine for bathroom breaks can help prevent accidents and improve the client's overall well-being.

Choice D reason:

Engage the client in activities that increase sensory stimulation is incorrect. While sensory stimulation activities can be enjoyable and engaging for individuals with dementia, it is essential to select activities that are appropriate and not overwhelming. Some individuals with dementia may become overstimulated, which can lead to agitation or distress. Activities should be tailored to the individual's preferences and abilities.

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.