A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Rationale:

A. I should visually monitor the client continuously when in mechanical restraints: Continuous visual monitoring is required when a client is placed in mechanical restraints to ensure safety, assess physical and psychological well-being, and promptly address any complications such as impaired circulation or distress.

B. I should ask the provider to write a prescription for mechanical restraints as needed: PRN (as needed) prescriptions for restraints are not permitted. A new, time-limited order must be obtained for each specific episode to ensure proper use and prevent misuse or overuse of restraints.

C. I should expect the provider to evaluate the client within 4 hours of restraint application: For adult clients, the provider must evaluate the client face-to-face within 1 hour of applying restraints, not 4 hours. This rule ensures timely review of the necessity and appropriateness of the intervention.

D. I should assess the client's skin integrity every 8 hours while in mechanical restraints: Skin integrity should be assessed at least every 2 hours or more frequently depending on facility policy. Waiting 8 hours increases the risk of skin breakdown and other complications.

Rationale for Correct Choices:

• Intravenous antibiotic: The client shows multiple signs of endometritis: uterine tenderness, foul-smelling lochia, fever, tachycardia, and elevated WBC count. IV antibiotics are the first-line treatment for postpartum uterine infections, particularly after cesarean delivery with risk factors like prolonged rupture of membranes.
• Increase in daily fluid intake: Clients with infection and fever require increased hydration to support perfusion, manage elevated metabolic demands, and help clear the infection. Fever and poor bowel motility may also contribute to mild dehydration, making fluid support essential.

Rationale for Incorrect Choices:

• Intrauterine tamponade balloon: This is used to control postpartum hemorrhage due to uterine atony or trauma. Although the fundus was boggy, it firmed with massage, and there is no indication of active or excessive bleeding, making tamponade unnecessary.
• Kleihauer-Betke test: This test detects fetal blood in the maternal circulation and is used after trauma or suspected fetal-maternal hemorrhage, especially in Rh-negative mothers. It is not relevant to this postpartum infection scenario.
• Tocolytic medication: Tocolytics are used during pregnancy to suppress preterm labor by relaxing the uterus. In the postpartum period, they are not indicated and would be contraindicated in the presence of infection, as they can reduce uterine tone and worsen involution.