A nurse is caring for a client who is 3 days postpartum in the postpartum unit.
A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take?
Obtain a prescription for a broad-spectrum antibiotic.
Initiate airborne isolation precautions.
Place the client on strict bedrest.
Instruct the client to stop breastfeeding.
The Correct Answer is A
A. Obtain a prescription for a broad-spectrum antibiotic.
The client's fever (38.5°C), chills, abdominal pain, malodorous lochia, and tender fundus suggest a potential postpartum infection, such as endometritis. Administering a broad-spectrum antibiotic is necessary to treat the infection. Given the clinical scenario, the nurse should prioritize addressing the client's symptoms and signs that suggest infection and support her well-being postpartum. Here's a breakdown of the appropriate actions:
B. Initiate airborne isolation precautions.
- Not necessary in this case. The client's symptoms and signs do not suggest an airborne infectious disease.
C. Place the client on strict bedrest.
- This is not necessary. While rest is important, strict bedrest may not be required and could increase the risk of other complications, such as deep vein thrombosis (DVT).
D. Instruct the client to stop breastfeeding.
- Not necessary unless there is a specific contraindication. Instead, the nurse can provide support and advice on managing engorgement and breastfeeding difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.
Choice B rationale
While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.
Choice C rationale
Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.
Choice D rationale
Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.
Correct Answer is D
Explanation
Choice A rationale
A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.
Choice B rationale
Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.
Choice C rationale
Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.
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