A nurse is assessing a client who has endometritis. Which of the following findings should the nurse expect?

Rationale:

A. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration by preventing gastric contents from entering the airway, especially during and after feeding.

B. Check gastric residuals every 4 hr: Regular residual checks help assess gastric emptying and tolerance of enteral feeding. High residuals may indicate delayed gastric motility and require intervention.

C. Check placement of the feeding tube by x-ray once daily: An x-ray is used only once to confirm initial tube placement. Daily x-rays are unnecessary unless dislodgement is suspected; routine placement verification is done via pH testing or aspiration.

D. Ensure the formula is cold before administration: Cold formula can cause cramping or discomfort. It should be at room temperature before administration to promote tolerance and reduce gastrointestinal side effects.

E. Change the feeding container and tubing every 24 hr: Changing feeding equipment every 24 hours prevents microbial contamination, especially with continuous feeding, and is consistent with infection control guidelines.

Rationale:

• Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
• Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
• Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
• Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
• Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.