A nurse is caring for a client who is 3 days postpartum in the postpartum unit.
A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take?
Obtain a prescription for a broad-spectrum antibiotic.
Initiate airborne isolation precautions.
Place the client on strict bedrest.
Instruct the client to stop breastfeeding.
The Correct Answer is A
A. Obtain a prescription for a broad-spectrum antibiotic.
The client's fever (38.5°C), chills, abdominal pain, malodorous lochia, and tender fundus suggest a potential postpartum infection, such as endometritis. Administering a broad-spectrum antibiotic is necessary to treat the infection. Given the clinical scenario, the nurse should prioritize addressing the client's symptoms and signs that suggest infection and support her well-being postpartum. Here's a breakdown of the appropriate actions:
B. Initiate airborne isolation precautions.
- Not necessary in this case. The client's symptoms and signs do not suggest an airborne infectious disease.
C. Place the client on strict bedrest.
- This is not necessary. While rest is important, strict bedrest may not be required and could increase the risk of other complications, such as deep vein thrombosis (DVT).
D. Instruct the client to stop breastfeeding.
- Not necessary unless there is a specific contraindication. Instead, the nurse can provide support and advice on managing engorgement and breastfeeding difficulties.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.
Choice B rationale
Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.
Choice C rationale
Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.
Choice D rationale
Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.
Correct Answer is ["B","C","D","E","F"]
Explanation
B. "You may experience a headache after receiving this medication."
- Some tocolytic medications can cause headaches as a side effect.
C. "It is common for this medication to make you feel jittery."
- Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.
D. "This medication should decrease your contractions."
- The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.
E. "I'll check your reflexes frequently while you are receiving this medication."
- Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.
F. "This medication can make your heart beat faster."
- Tocolytic medications, such as terbutaline, can increase heart rate.
These statements provide the client with a comprehensive understanding of the purpose of the medication and its potential side effects.
The incorrect statements are:
- A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
- G. "This medication can increase your blood pressure.": Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
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