A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

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.

Rationale:

A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm, even with visitors present, eliminates an essential safety mechanism. The presence of visitors does not guarantee client supervision, and falls can still occur if the client attempts to get up unexpectedly.

B. Establish an elimination schedule for the client: Creating a toileting schedule helps reduce the likelihood of the client attempting to ambulate independently to the bathroom, which is a common time for falls. This proactive approach promotes safety and preserves dignity.

C. Allow the client to walk unassisted near the nursing station: Even when close to staff, allowing a fall-risk client to walk unassisted increases the chance of injury. Supervision does not replace physical support or assistive devices for those at risk.

D. Raise all four bed rails on the client's bed: Raising all four bed rails is considered a form of restraint and may increase injury risk if the client attempts to climb over them. Instead, using two rails and other fall precautions is safer and more appropriate.