A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Rationale:

A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.

B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.

C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.

D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.

E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.

F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.

G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.

Rationale:

A. Clamp the catheter distal to the injection port: Clamping the catheter allows urine to accumulate in the tubing, ensuring a fresh specimen can be obtained from the sampling port rather than from stagnant urine in the drainage bag, which could be contaminated.

B. Drain the specimen from the drainage bag: Urine in the drainage bag may be old and contaminated, which can lead to inaccurate culture results. Specimens should be collected aseptically from the catheter sampling port.

C. Collect 2 mL of urine for each specimen: For accurate urinalysis and culture, a larger volume typically 3–10 mL for culture and 10–15 mL for routine urinalysis is recommended to ensure enough specimen for testing and repeat analysis if needed.

D. Obtain the urinalysis specimen before the culture specimen: Culture specimens should be collected first to prevent contamination. Performing urinalysis first can alter the bacterial composition of the sample and compromise culture accuracy.