A nurse is caring for a female client who is 3 days postpartum in the postpartum unit.
Which of the following actions should the nurse take?
Instruct the client to stop breastfeeding.
Obtain a prescription for a broad-spectrum antibiotic.
Initiate airborne isolation precautions.
Place the client on strict bedrest.
The Correct Answer is B
Choice A rationale: Stopping breastfeeding is not indicated in postpartum infections unless the infection is a contraindication such as HIV or active tuberculosis. Breastfeeding promotes uterine contraction by releasing oxytocin, which helps reduce bleeding and promotes healing. Additionally, breast milk provides immunological benefits to the newborn. The client’s infection appears localized to the uterus (endometritis), and there is no evidence breastfeeding worsens maternal infection or neonatal risk here.
Choice B rationale: Initiating broad-spectrum antibiotics is scientifically appropriate for suspected postpartum endometritis, especially with fever >38°C, tachycardia, foul-smelling lochia, and abdominal tenderness. These antibiotics target polymicrobial infections commonly involving aerobic and anaerobic bacteria, preventing progression to sepsis. Timely antibiotic therapy reduces maternal morbidity and accelerates recovery. Normal temperature is 36.5–37.5°C; this client’s rising fever to 38.9°C indicates infection requiring treatment.
Choice C rationale: Airborne isolation precautions are unnecessary because common postpartum infections such as endometritis are not transmitted via airborne routes but rather by endogenous flora or direct contamination. Airborne pathogens include tuberculosis, varicella, and measles, none of which are suggested by this client’s presentation or history. Implementing unnecessary airborne precautions wastes resources and increases patient isolation without scientific benefit.
Choice D rationale: Strict bedrest is not routinely indicated in postpartum infections unless severe systemic illness is present. Early mobilization improves circulation, reduces risk of venous thromboembolism, and promotes pulmonary function, especially when respiratory rate is elevated at 24/min. The client is alert and breastfeeding, suggesting stable condition. Prolonged immobility increases risks without benefits in mild-to-moderate infection management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fetal cardiac activity is typically detectable via transvaginal ultrasound as early as 5.5 to 6 weeks gestational age, when the embryo is approximately 2-4 mm in crown-rump length. However, hearing the heartbeat with a Doppler stethoscope usually occurs later, around 10 to 12 weeks, as the fetal heart is still very small and sound transmission is limited.
Choice B rationale
The standard schedule for prenatal visits involves monthly appointments from the first prenatal visit until 28 weeks of gestation. This frequency allows for consistent monitoring of maternal and fetal well-being, early detection of potential complications, and timely interventions. After 28 weeks, visits typically become more frequent.
Choice C rationale
While a complete blood count (CBC) is a crucial laboratory test performed during pregnancy, it is not typically done at every prenatal visit. Initial CBCs are obtained at the first prenatal visit to establish baseline values, and then repeated later in pregnancy, often around 28 weeks, to screen for anemia and other hematologic changes.
Choice D rationale
Screening for neural tube defects, often through maternal serum alpha-fetoprotein (MSAFP) testing, is typically performed between 15 and 20 weeks of gestation. This timing is crucial for accurate interpretation of results and allows for further diagnostic evaluation if abnormalities are detected, well before 32 weeks.
Correct Answer is A
Explanation
Choice A rationale
Encouraging the client to listen to music is an effective non-pharmacological pain management strategy in the latent phase of labor. Music provides a distraction, promotes relaxation, and can help to reduce the perception of pain by stimulating the release of endorphins, fostering a calmer environment and coping mechanism.
Choice B rationale
Instructing the client on biofeedback is a complex technique that requires training and practice for effective use. While it can be beneficial, the latent phase of labor may not be the ideal time to introduce and teach a new skill like biofeedback, as the client's focus may be limited by contractions and discomfort.
Choice C rationale
Administering fentanyl 100 mcg every hour via intermittent intravenous bolus is a pharmacological intervention typically used for more intense pain in active labor or for clients who desire or require stronger pain relief. The latent phase is characterized by milder, less frequent contractions, making non-pharmacological methods or lower-dose analgesics more appropriate.
Choice D rationale
Requesting a pudendal nerve block is usually reserved for the second stage of labor, specifically for episiotomy repair or forceps delivery, rather than for pain management during the latent phase. It provides regional anesthesia to the perineum and lower vagina, not generalized pain relief for uterine contractions in early labor.
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