A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?

Cleanse the perineum with 0.9% sodium chloride after bowel movements

Obtain serial blood cultures.

Insert and maintain an indwelling urinary catheter.

Encourage the use of a sitz bath twice a day,

Answer and Explanation

The Correct Answer is B

Rationale:

A. Cleanse the perineum with 0.9% sodium chloride after bowel movements: While perineal hygiene is important postpartum, cleansing with normal saline is more routine care and does not specifically target endometritis management.

B. Obtain serial blood cultures: Endometritis is a uterine infection that can lead to bacteremia or sepsis. Serial blood cultures help identify the causative organism and guide antibiotic therapy.

C. Insert and maintain an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not routinely used unless there is urinary retention or other specific indications.

D. Encourage the use of a sitz bath twice a day: Sitz baths promote perineal comfort and hygiene but do not directly treat uterine infections like endometritis. They may be recommended for perineal pain but are not primary treatment for endometritis.

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Correct Answer is B

Explanation

Rationale:

A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.

B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.

C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.

D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.

A. "You should eat three large meals and two snacks per day." B. "You should elevate the head of the bed while sleeping C. "You should only drink 2 cups of coffee per day." D. "You should lay down for 1 hour following a meal."

Correct Answer is B

Explanation

Rationale:

A. "You should eat three large meals and two snacks per day." Eating large meals increases gastric pressure and can worsen reflux symptoms by promoting the backflow of stomach acid into the esophagus. Clients with GERD are advised to consume smaller, more frequent meals to reduce gastric distention.

B. "You should elevate the head of the bed while sleeping." Elevating the head of the bed helps prevent nighttime reflux by using gravity to reduce the likelihood of stomach acid flowing back into the esophagus. This is a key non-pharmacologic strategy in managing GERD symptoms during sleep.

C. "You should only drink 2 cups of coffee per day." Coffee, regardless of the quantity, can relax the lower esophageal sphincter and stimulate acid production. Rather than limiting intake to two cups, clients with GERD are often advised to avoid coffee altogether or monitor symptoms closely.

D. "You should lay down for 1 hour following a meal." Lying down after eating increases the risk of acid reflux due to the horizontal position reducing the effect of gravity. Clients should remain upright for at least 2 to 3 hours after meals to minimize reflux episodes.

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A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?