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

Exhibits

The nurse should anticipate a provider's prescription for a(n)

and .
Answer and Explanation

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

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.


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Related Questions

Correct Answer is C

Explanation

Rationale:

A. "Decrease your intake of cranberry juice.": Cranberry juice is not known to worsen urge incontinence. It is more commonly used for urinary tract health. There is no need to reduce it unless the client finds it personally irritating.

B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence. Adequate hydration is essential for bladder health.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding helps retrain the bladder by establishing regular emptying times and reducing urgency. Over time, this improves bladder control and reduces incontinence episodes.

D. "Take your diuretic medication with your evening meal.": Diuretics should be taken in the morning to avoid nocturia and sleep disturbances. Evening dosing increases the risk of nighttime incontinence due to increased urine production during sleep.

Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. Provide a quiet environment for the client: Minimizing noise and stimulation helps reduce stress and prevents spikes in intracranial pressure (ICP). A calm environment is essential for neurologically compromised clients.

B. Encourage the client to cough and deep breathe: Coughing can increase thoracic pressure and, consequently, ICP. In clients with elevated ICP, activities that increase intrathoracic or intra-abdominal pressure should be avoided to prevent worsening brain injury.

C. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, often hourly or every 2–4 hours, to detect changes in neurologic status or signs of Cushing's triad. Every 8 hours is insufficient for early intervention.

D. Maintain the head of the bed at a 30 degree angle: Elevating the head promotes venous outflow from the brain without compromising perfusion. A 30-degree elevation is a commonly recommended position to help control ICP levels.

E. Administer stool softeners to the client: Straining during bowel movements increases intra-abdominal pressure and can elevate ICP. Stool softeners reduce this risk and are a supportive intervention in the management of increased ICP.

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