A nurse reviews the provider prescriptions and reassesses the client.

Exhibits

The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

A. Wear loose-fitting clothing. After ICD implantation, the site may be sore or swollen, and tight clothing can cause irritation or pressure. Loose-fitting clothes help protect the incision and device, reducing discomfort and risk of complications.
B. Return in two weeks for a follow-up MRI. Most implantable cardioverter/defibrillators are not MRI-compatible unless specifically labeled as such. MRI exposure can interfere with device function and is generally avoided unless approved by a cardiologist.
C. Expect to have a rapid pulse rate for the first few weeks. The purpose of an ICD is to monitor and correct life-threatening arrhythmias, not to increase the heart rate. A rapid pulse is not expected and may indicate a complication requiring immediate evaluation.
D. Resume tub baths and swimming after 24 hr. Immersing the incision site in water within the first few weeks post-op increases the risk of infection. The client should avoid soaking the incision until it is fully healed, typically 1 to 2 weeks post-procedure.

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.