A nurse is planning care for a client who is at 36 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse plan to implement?

Rationale for Correct Choices

• Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
• Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.

Rationale for Incorrect Choices

• Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
• Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
• Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.

Rationale:

• Measure the infant's weight daily: Daily weight monitoring is standard for postoperative infants to assess hydration status and overall recovery. Accurate weight helps guide fluid replacement and nutrition management.

• Initiate short breastfeeding sessions 12 hr postoperatively: Postoperative feedings usually begin relatively quickly (often 4-6 hours post-op) with small amounts of clear fluids or breast milk/formula, gradually increasing. 12 hours is an expected time frame to begin re-feeding/breastfeeding sessions.

• Place the infant in prone position after feeding: Infants are placed on their backs (supine) to reduce the risk of sudden infant death syndrome (SIDS). Prone positioning after feeding is not recommended in postoperative care unless specifically ordered for surgical reasons.

• Fold the infant's diaper below the incision site: Keeping the diaper below the surgical site prevents irritation, friction, or pressure on the incision, promoting healing and preventing infection. This is a standard nursing intervention after abdominal surgery in infants.