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 C
Explanation
A. Place the client in a supine position. As clients near the end of life, the supine position may compromise breathing. A semi-Fowler’s or lateral position is usually preferred to promote comfort and respiratory ease.
B. Remind the client to eat scheduled meals daily. At the end of life, appetite typically decreases, and forcing food can cause discomfort. Nutrition should be offered based on the client's desire, not forced on a strict schedule.
C. Offer the client a blanket to keep warm. Clients nearing death often experience peripheral circulation decline, leading to feelings of coldness. Providing a blanket promotes comfort and warmth without being invasive.
D. Speak in a loud tone when addressing the client. Loud speech can be disorienting and distressing, especially if the client is already weak or confused. Use a calm, clear, and gentle tone to provide comfort and maintain dignity.
Correct Answer is C
Explanation
A. Apply the largest cuff available. Using a cuff that is too large can result in falsely low readings. Cuff size should match the client’s arm circumference to ensure accuracy, but simply switching to the largest cuff does not resolve difficulty in auscultation.
B. Deflate the cuff quickly. Rapid deflation can cause the nurse to miss the systolic and diastolic sounds, making it harder to obtain an accurate reading. The cuff should be deflated at a steady rate of 2–3 mmHg per second.
C. Use the palpatory method to determine blood pressure. When sounds are difficult to auscultate, the palpatory method is a reliable alternative. This involves palpating the radial pulse while inflating the cuff to estimate systolic pressure, which helps guide a more accurate auscultatory attempt.
D. Place the arm above the level of the client's heart. Elevating the arm above heart level can lower the pressure artificially, resulting in an inaccurate measurement. For correct results, the arm should be supported at heart level.
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