A nurse reviews the provider prescriptions and reassesses the client.
The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.
Request a prescription for terbutaline from the provider.
Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab.
Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr.
Initiate contact precautions.
Monitor the height and tone of the client's fundus.
Instruct the client to wash her hands before and after changing her perineal pad.
Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage.
Correct Answer : B,E,F,G
A. Request a prescription for terbutaline from the provider. Terbutaline is a tocolytic used to stop preterm labor, not indicated in this postpartum scenario. The client is already on uterotonic therapy (methylergonovine), which is appropriate for postpartum uterine atony.
B. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab. This is appropriate because the client’s lochia is foul-smelling, indicating a possible endometrial infection (endometritis). Culturing the lochia helps guide antibiotic therapy.
C. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr. This is incorrect. Breastfeeding is usually safe with most antibiotics, including clindamycin, and mothers with postpartum infections can typically continue breastfeeding unless advised otherwise by the provider.
D. Initiate contact precautions. Contact precautions are not necessary unless the client has an identified or suspected infection that is transmissible by direct contact (e.g., MRSA). Standard precautions are sufficient for routine postpartum care and suspected endometritis.
E. Monitor the height and tone of the client’s fundus. The fundus is tender and was initially boggy, indicating risk for uterine atony or subinvolution. Monitoring tone and height helps detect complications such as hemorrhage or infection.
F. Instruct the client to wash her hands before and after changing her perineal pad. Hand hygiene is essential to prevent the spread of infection to the perineal area or incision and to promote general postpartum hygiene.
G. Encourage the client to maintain a semi-Fowler’s position to enhance uterine drainage. This position helps promote lochia drainage, reduce uterine pooling, and may help with comfort and resolution of infection by improving uterine drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
- 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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