A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Rationale for correct choices:

• Spontaneous abortion: The client is at risk of a spontaneous abortion, as evidenced by bright red vaginal bleeding, cramping, and an open cervix at 10 weeks gestation. These findings are classic for an inevitable abortion, particularly when fetal viability has not been confirmed and symptoms are active.
• Cervical dilation: Cervical dilation during the first trimester, especially in conjunction with vaginal bleeding and uterine cramping, confirms that the miscarriage process is in progress. In a viable pregnancy, the cervix remains closed, so dilation is a key indicator of pregnancy loss.

Rationale for incorrect choices:

• Molar pregnancy: While molar pregnancies can cause elevated hCG levels, they typically present with painless bleeding, absence of a fetus on ultrasound, and may show signs like early-onset preeclampsia or hyperemesis. The presence of pain and cervical dilation points away from a molar pregnancy.
• Ectopic pregnancy: An ectopic pregnancy more often presents with sharp unilateral lower abdominal pain, low or slowly rising hCG levels, and an empty uterus on ultrasound. The findings of cervical dilation and an hCG level consistent with intrauterine pregnancy reduce the likelihood of an ectopic pregnancy.
• Bright red vaginal bleeding: Although bright red bleeding suggests active hemorrhage and is concerning, it can occur in a variety of obstetric conditions. Without cervical dilation or signs of fetal compromise, it cannot alone confirm spontaneous abortion.
• History of chlamydia infection: While a history of chlamydia increases the risk of ectopic pregnancy due to tubal scarring, it is not a direct indicator of current pregnancy loss. It does not outweigh the importance of current symptoms like cervical dilation in determining the client's current risk.

Rationale:

A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics, including clindamycin, are safe for breastfeeding. Mothers are encouraged to continue breastfeeding unless the medication is contraindicated, which it is not in this case.

B. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene prevents spread of infection, particularly in clients with postpartum endometritis who are shedding infectious organisms in lochia. Handwashing is a key element in infection control.

C. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes lochial drainage by using gravity, reducing the risk of retained secretions and supporting infection resolution.

D. Monitor the height and tone of the client's fundus: Fundal monitoring is essential for assessing uterine involution and identifying worsening atony or infection. A boggy uterus may indicate continued risk for hemorrhage or poor uterine tone.

E. Initiate contact precautions: Endometritis is not a condition requiring contact isolation unless there is evidence of another communicable infection (e.g., C. difficile). Standard precautions are sufficient.

F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic that relaxes uterine muscle and is used to delay preterm labor. It is contraindicated postpartum and would worsen uterine atony.

G. Obtain a culture specimen of the lochia from the client's perineal pad using sterile swab: A lochia culture can identify the causative pathogen of suspected endometritis and guide antibiotic therapy if initial treatment is ineffective.