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A nurse on a postpartum unit is caring for a client.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should anticipate a provider's prescription for an

and
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

  • Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not applicable for this postpartum client. There is no indication of uterine contractions needing suppression.
  • Intravenous antibiotic: The client exhibits signs of postpartum endometritis—including fever, uterine tenderness, foul-smelling lochia, and a very high WBC count (33,000/mm³). These findings strongly support the need for IV antibiotics to treat the infection.
  • Intrauterine tamponade balloon: This device is used for managing postpartum hemorrhage, which is not present in this case. The client’s lochia is moderate, not excessive, and her uterus is responding to massage.
  • Kleihauer-Betke test: This test is used to detect fetal-to-maternal hemorrhage, particularly in Rh-negative mothers after trauma or potential placental separation. It is not relevant in the context of postpartum infection.
  • Increase in daily fluid intake: The client is febrile and shows signs of systemic infection. Increased fluids support hydration, promote recovery, and help manage the effects of fever and infection, making this an appropriate supportive measure.


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Related Questions

Correct Answer is ["B","D"]

Explanation

A. Remove the thermometer from client's room for use on another client. Clients with C. difficile should have dedicated equipment (e.g., thermometers, stethoscopes) to prevent cross-contamination. Reusing equipment between patients increases the risk of infection transmission.
B. Wear a gown when providing care. Contact precautions are required for clients with C. difficile, including wearing a gown to protect against contamination from infectious material or surfaces.
C. Wear an N95 respirator when providing care. C. difficile is spread through the fecal-oral route, not airborne. A surgical mask is not required, and an N95 respirator is unnecessary unless another airborne condition is present.
D. Change gloves after contact with infectious material. Gloves must be changed after contact with contaminated materials to prevent spreading spores to other surfaces or clients. This is a standard part of contact precaution practices.
E. Wash hands with an alcohol-based cleaner. Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required after caring for a client with this infection to properly remove the spores.

Correct Answer is A

Explanation

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

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