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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 A

Explanation

A. "I should visually monitor the client continuously when in mechanical restraints." Continuous visual monitoring is required to ensure the client’s safety, monitor for distress or injury, and assess the ongoing need for restraints. This is a key safety standard in the use of mechanical restraints.
B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." Skin integrity must be assessed much more frequently, typically every 15 to 30 minutes, to prevent injury or pressure-related complications while the client is restrained.
C. "I should expect the provider to evaluate the client within 4 hours of restraint application." For adults, a provider must evaluate the client within 1 hour of the initiation of mechanical restraints. A 4-hour delay does not meet safety or legal standards.
D. "I should ask the provider to write a prescription for mechanical restraints as needed." PRN (as-needed) prescriptions for restraints are not permitted. Each use must be justified, time-limited, and based on the client’s immediate behavior or condition.

Correct Answer is C

Explanation

A. Ketorolac. This is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.
B. Aspirin. Aspirin is also an NSAID and can irritate the gastric lining, increasing the risk of ulceration and bleeding. It is contraindicated in clients with peptic ulcers.
C. Acetaminophen. Acetaminophen is the safest option for clients with peptic ulcer disease because it does not affect the gastric mucosa. It provides effective relief for mild to moderate pain, including headaches.
D. Ibuprofen. Like ketorolac and aspirin, ibuprofen is an NSAID and is not recommended for clients with peptic ulcers due to the increased risk of gastrointestinal irritation and bleeding.

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