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A nurse is caring for a client in the medical-surgical unit.

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Encourage the client to drink 3000 mL of fluid daily.

Review the need for the indwelling urinary catheter daily.

Empty the drainage bag when it is half-full.

Use soap and water to provide perineal care.

Place the drainage bag on the bed when transporting the client.

Change the indwelling urinary catheter tubing every 3 days.

Answer and Explanation

Correct Answer : B,C,D

Rationale:

A. Encourage the client to drink 3000 mL of fluid daily: This is contraindicated because the client has heart failure with signs of fluid volume excess (crackles and 3+ pitting edema). Increasing fluid intake could worsen fluid overload.

B. Review the need for the indwelling urinary catheter daily: Daily assessment of catheter necessity allows for timely removal when it is no longer needed, which significantly decreases the risk of catheter-associated urinary tract infections (CAUTIs).

C. Empty the drainage bag when it is half-full: Keeping the drainage bag from becoming overfilled prevents urine backflow into the bladder, which can introduce bacteria and increase infection risk. Regular emptying is a key preventive measure.

D. Use soap and water to provide perineal care: Proper perineal hygiene with mild soap and water helps remove bacteria and maintain skin integrity, reducing the risk of urinary tract infection, especially in incontinent clients.

E. Place the drainage bag on the bed when transporting the client: The drainage bag should always remain below the level of the bladder and off the bed to prevent backflow of urine, which can introduce bacteria and increase infection risk.

F. Change the indwelling urinary catheter tubing every 3 days: Routine scheduled tubing changes are not recommended, as unnecessary manipulation of the system can increase infection risk. Tubing should only be changed when clinically indicated (e.g., contamination, obstruction).

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Correct Answer is D

Explanation

A. Fundus 2 fingerbreadths above the umbilicus: This finding relates to uterine involution rather than urinary elimination. While important for postpartum assessment, it does not indicate restored bladder function.

B. Uterine atony: Uterine atony is a complication that increases the risk of postpartum hemorrhage. It does not provide information about the client’s ability to void and requires separate monitoring and intervention.

C. Fundus firm and to the right of the abdominal midline: A firm but displaced fundus may indicate a full bladder, which can interfere with urination. This finding suggests bladder distention rather than restored urinary elimination.

D. Two voids of 150 mL each over the past 2 hr: Adequate urine output in regular intervals indicates that the bladder is emptying effectively. Measuring volume and frequency confirms the client’s ability to eliminate urine has been restored postpartum.

A. Progestin oral contraceptive B. Vaginal etonogestrel/ethinyl estradiol contraceptive ring C. Transdermal estrogen/progesterone patch D. Injectable synthetic progestin

Correct Answer is A

Explanation

A. Progestin oral contraceptive: Progestin-only oral contraceptives (often called the “mini-pill”) are safe to use immediately postpartum for breastfeeding clients because they do not affect milk production. They provide effective contraception without the risks associated with estrogen-containing methods.

B. Vaginal etonogestrel/ethinyl estradiol contraceptive ring: Combination estrogen-progestin contraceptives, such as the vaginal ring, are generally not recommended immediately postpartum for breastfeeding clients because estrogen can reduce milk supply and may increase the risk of thromboembolism.

C. Transdermal estrogen/progesterone patch: Similar to other estrogen-containing methods, the transdermal patch is not recommended immediately postpartum for breastfeeding clients due to potential interference with lactation and increased thromboembolism risk.

D. Injectable synthetic progestin: Injectable progestin (e.g., depot medroxyprogesterone acetate) is safe for breastfeeding, but it is not ideal for immediate postpartum use if the client wishes for rapid return to fertility later, since its effects can last for several months. It may also have delayed effects on bone density with long-term use.

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A nurse is caring for a client in the medical-surgical unit. Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

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A nurse is caring for a client in the medical-surgical unit.

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.