A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Rationale:

A. Pale and a 24-hr fluid deficit of 30 mL: Mild pallor and a small fluid deficit are not uncommon in early stages of illness and may not require immediate intervention. However, more serious signs of dehydration would take priority for reporting.

B. Temperature 38° C (100.4° F) and pulse rate 124/min: These are within expected limits for an infant with mild infection or fever. While they should be monitored, they are not urgent indicators of severe complications from gastroenteritis.

C. Decreased appetite and irritability: These are common symptoms in infants with viral illnesses, including gastroenteritis. Although they affect comfort and feeding, they are not necessarily indicators of serious fluid or electrolyte imbalance.

D. Sunken fontanels and dry mucous membranes: These are clinical signs of moderate to severe dehydration, which is a serious complication of gastroenteritis in infants. These findings must be reported promptly for urgent intervention to prevent further deterioration.

Rationale:

A. Initiate contact precautions: Endometritis is not typically caused by a pathogen requiring contact precautions (like MRSA or C. difficile). Standard precautions are sufficient unless otherwise indicated.

B. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: The prescribed antibiotics (e.g., clindamycin) are generally considered safe for breastfeeding, and lactation should be encouraged unless specifically contraindicated.

C. Monitor the height and tone of the client's fundus: Fundal tenderness, foul-smelling lochia, and fever are signs of endometritis. Ongoing fundal assessment is important to evaluate uterine involution and identify potential complications like subinvolution or abscess formation.

D. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to relax the uterus in cases of hyperstimulation during labor not for treating uterine infection or postpartum discomfort.

E. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Culturing lochia helps identify the causative organism of the uterine infection and guide antibiotic therapy. This is a standard step in suspected endometritis cases.

F. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Positioning the client with the head elevated allows for better lochia drainage, preventing accumulation that could worsen infection or discomfort.

G. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene helps prevent the spread of infection and supports recovery, especially in the context of suspected endometritis.