A nurse is caring for a female client who is 3 days postpartum in the postpartum unit.
Which of the following actions should the nurse take?
Instruct the client to stop breastfeeding.
Obtain a prescription for a broad-spectrum antibiotic.
Initiate airborne isolation precautions.
Place the client on strict bedrest.
The Correct Answer is B
Choice A rationale: Stopping breastfeeding is not indicated in postpartum infections unless the infection is a contraindication such as HIV or active tuberculosis. Breastfeeding promotes uterine contraction by releasing oxytocin, which helps reduce bleeding and promotes healing. Additionally, breast milk provides immunological benefits to the newborn. The client’s infection appears localized to the uterus (endometritis), and there is no evidence breastfeeding worsens maternal infection or neonatal risk here.
Choice B rationale: Initiating broad-spectrum antibiotics is scientifically appropriate for suspected postpartum endometritis, especially with fever >38°C, tachycardia, foul-smelling lochia, and abdominal tenderness. These antibiotics target polymicrobial infections commonly involving aerobic and anaerobic bacteria, preventing progression to sepsis. Timely antibiotic therapy reduces maternal morbidity and accelerates recovery. Normal temperature is 36.5–37.5°C; this client’s rising fever to 38.9°C indicates infection requiring treatment.
Choice C rationale: Airborne isolation precautions are unnecessary because common postpartum infections such as endometritis are not transmitted via airborne routes but rather by endogenous flora or direct contamination. Airborne pathogens include tuberculosis, varicella, and measles, none of which are suggested by this client’s presentation or history. Implementing unnecessary airborne precautions wastes resources and increases patient isolation without scientific benefit.
Choice D rationale: Strict bedrest is not routinely indicated in postpartum infections unless severe systemic illness is present. Early mobilization improves circulation, reduces risk of venous thromboembolism, and promotes pulmonary function, especially when respiratory rate is elevated at 24/min. The client is alert and breastfeeding, suggesting stable condition. Prolonged immobility increases risks without benefits in mild-to-moderate infection management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Cooling the newborn's heel causes vasoconstriction, which reduces blood flow to the area. This would make it more difficult to obtain an adequate blood sample and could lead to repeated punctures, increasing the risk of discomfort and tissue damage for the newborn. Optimal blood flow is crucial for a successful heel stick.
Choice B rationale
Puncturing the center of the newborn's heel risks damaging the calcaneus bone, which can lead to osteomyelitis, an infection of the bone. The proper technique involves puncturing the lateral aspects of the heel to avoid bone injury and ensure patient safety.
Choice C rationale
Cleansing the puncture site with an alcohol gauze pad prior to the procedure is essential for asepsis. Alcohol acts as an antiseptic by denaturing proteins and dissolving lipids in bacterial cell membranes, effectively reducing the microbial load on the skin surface and minimizing the risk of introducing pathogens into the bloodstream during the puncture.
Choice D rationale
Administering vitamin K is typically done shortly after birth to prevent hemorrhagic disease of the newborn, as newborns have immature livers and insufficient gut flora for vitamin K synthesis. It is not routinely administered 30 minutes prior to every blood draw and is unrelated to the immediate procedure of obtaining a heel stick sample.
Correct Answer is A
Explanation
Choice A rationale
A BUN level of 25 mg/dL is above the normal range of 10 to 20 mg/dL for pregnant clients. Elevated BUN can indicate impaired renal function, which can be a complication of pregnancy, particularly in conditions like preeclampsia or underlying kidney disease. This finding, especially in a client with a history of anemia, warrants further investigation as it suggests potential kidney compromise affecting waste product excretion.
Choice B rationale
A hemoglobin (Hgb) level of 10.2 mg/dL is slightly below the normal range of 11 to 16 mg/dL for pregnant clients. Given the client's history of anemia, this finding is consistent with their known condition and, while it indicates mild anemia, it might not necessarily represent a new acute prenatal complication requiring immediate report unless there is a significant drop or associated symptoms. Iron supplementation is typically initiated for this level.
Choice C rationale
A fasting blood glucose of 70 mg/dL is within the normal range of 70 to 110 mg/dL. This indicates adequate glucose regulation and does not suggest a prenatal complication such as gestational diabetes. Maintaining a normal fasting blood glucose is a positive indicator for maternal and fetal well-being, especially for a client without a history of diabetes.
Choice D rationale
A hematocrit (Hct) level of 32% is slightly below the normal range of 33 to 47% for pregnant clients. Similar to hemoglobin, a slightly low hematocrit is common in pregnancy due to hemodilution, where plasma volume increases more significantly than red blood cell mass. While it indicates mild physiological anemia, it is often managed with dietary adjustments or iron supplements and does not typically signify an acute prenatal complication requiring immediate report.
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