A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Rationale for Correct Choices:

• Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
• Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

• Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
• Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
• Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
• Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.

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.