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 : 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 is inappropriate because the pad is asceptic.
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. "Administer this medication as needed for symptom control." Fluticasone is an inhaled corticosteroid used for long-term control, not for acute symptom relief. It should be administered on a regular schedule, not as needed.
B. "Rinse mouth and gargle with water after each use." Rinsing the mouth helps prevent oral thrush (candidiasis), a common side effect of inhaled corticosteroids like fluticasone. It reduces residual medication in the mouth and supports good oral hygiene.
C. “Administer this medication before any other inhaled medications.” Fluticasone should be given after bronchodilators, such as albuterol, if both are prescribed. Administering a bronchodilator first opens the airways and allows the corticosteroid to work more effectively.
D. "Growth may be accelerated while using this medication?” Inhaled corticosteroids may cause slowed growth in some children with long-term use, though the effect is generally small and outweighed by the benefits of asthma control.
Correct Answer is C
Explanation
A. Tell the nurses that the assignments will be more equitable in the future. While this acknowledges their concern, it does not involve the nurses in the resolution process or address the root of the conflict through direct communication.
B. Ask each nurse to take turns making the assignments. This may temporarily reduce tension but avoids addressing the underlying issues of perceived favoritism and does not encourage collaboration or accountability.
C. Encourage collaboration between the two nurses when making the assignments. This approach promotes open communication, mutual understanding, and shared decision-making, which are key elements of collaborative conflict resolution. It allows both nurses to express their perspectives and work toward a fair and balanced outcome.
D. Arrange for the nurses to have as few shifts together as possible. This strategy avoids the conflict rather than resolving it, which may only delay or worsen interpersonal issues over time. It also limits opportunities for growth and team building.
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