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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

While weight gain is crucial during pregnancy, a blanket statement of 2 pounds per week is not universally appropriate. The recommended rate of weight gain varies based on the client's pre-pregnancy BMI and the trimester. Excessive or insufficient weight gain can lead to adverse maternal and fetal outcomes, including macrosomia or intrauterine growth restriction, highlighting the need for individualized nutritional guidance rather than a fixed weekly gain.

Choice B rationale

Dieting during pregnancy, especially restrictive calorie intake, can significantly compromise the nutrient supply to the developing fetus. Fetal growth and organogenesis are highly dependent on adequate maternal nutritional stores and daily nutrient intake. Inadequate nutrition can lead to low birth weight, premature birth, and long-term health complications for the infant, emphasizing the dangers of unguided dietary restrictions.

Choice C rationale

A dietitian possesses specialized knowledge in medical nutrition therapy and can provide personalized recommendations based on the adolescent's specific nutritional needs, gestational age, and pre-pregnancy weight. This collaborative approach ensures optimal maternal and fetal health by addressing any deficiencies, managing appropriate weight gain, and promoting healthy eating habits throughout the pregnancy, which is crucial for adolescent development and pregnancy outcomes.

Choice D rationale

The caloric needs of a pregnant adolescent increase in the second and third trimesters, but a fixed additional 700 calories per day may not be accurate for all individuals. Caloric requirements are dynamic and depend on pre-pregnancy weight, activity level, and the specific stage of gestation. Overestimation can lead to excessive weight gain, while underestimation can result in inadequate fetal growth, necessitating individualized assessment.

A. BUN 25 mg/dL (10 to 20 mg/dL). B. Hgb 10.2 mg/dL (11 to 16 mg/dL). C. Fasting blood glucose 70 mg/dL (70 to 110 mg/dL). D. Hct 32% (33 to 47%).

Correct Answer is A

Explanation

Choice A rationale

A BUN level of 25 mg/dL is above the normal range of 10 to 20 mg/dL for pregnant clients. Elevated BUN can indicate impaired renal function, which can be a complication of pregnancy, particularly in conditions like preeclampsia or underlying kidney disease. This finding, especially in a client with a history of anemia, warrants further investigation as it suggests potential kidney compromise affecting waste product excretion.

Choice B rationale

A hemoglobin (Hgb) level of 10.2 mg/dL is slightly below the normal range of 11 to 16 mg/dL for pregnant clients. Given the client's history of anemia, this finding is consistent with their known condition and, while it indicates mild anemia, it might not necessarily represent a new acute prenatal complication requiring immediate report unless there is a significant drop or associated symptoms. Iron supplementation is typically initiated for this level.

Choice C rationale

A fasting blood glucose of 70 mg/dL is within the normal range of 70 to 110 mg/dL. This indicates adequate glucose regulation and does not suggest a prenatal complication such as gestational diabetes. Maintaining a normal fasting blood glucose is a positive indicator for maternal and fetal well-being, especially for a client without a history of diabetes.

Choice D rationale

A hematocrit (Hct) level of 32% is slightly below the normal range of 33 to 47% for pregnant clients. Similar to hemoglobin, a slightly low hematocrit is common in pregnancy due to hemodilution, where plasma volume increases more significantly than red blood cell mass. While it indicates mild physiological anemia, it is often managed with dietary adjustments or iron supplements and does not typically signify an acute prenatal complication requiring immediate report.

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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?