A nurse is caring for a client who is scheduled for a surgical procedure and states, "I don't want to have this surgery anymore." Which of the following responses should the nurse make?

A. Explaining the steps for a 24-hr urine collection: Teaching and explaining procedures require nursing knowledge and judgment, which are outside the scope of practice for assistive personnel.

B. Interpreting blood glucose values: Interpretation of lab results requires clinical judgment and assessment skills, which must be performed by a licensed nurse.

C. Performing postmortem care: Postmortem care is a noninvasive task that focuses on preparing the body, maintaining dignity, and basic hygiene. This task is within the scope of practice for assistive personnel.

D. Assisting with low-carbohydrate diet selections: Assisting with dietary teaching or making food choices involves clinical guidance and education, which must be performed by a licensed nurse or dietitian rather than an assistive personnel.

Rationale:

A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.

B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.

C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.

D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.

E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.

F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.

G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.