A nurse on a postpartum unit is caring for a client.
Monitor the height and tone of the client’s fundus.
Request a prescription for terbutaline from the provider.
Encourage the client to maintain a semi-Fowler’s position to enhance uterine drainage.
Initiate contact precautions.
Instruct the client to wash her hands before and after changing her perineal pad.
Obtain a culture specimen of the lochia from the client’s perineal pad using a sterile swab.
Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr.
Correct Answer : A,C,E
Rationale:
A. Monitor the height and tone of the client’s fundus: The fundus is currently high 1 cm above the umbilicus and described as boggy (though it firmed with massage), suggesting subinvolution. Endometritis often interferes with involution, leading to a higher, softer (boggy) uterus. Frequent monitoring is necessary to check for hemorrhage and track the progress of the infection.
B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic (used to stop contractions) and is contraindicated here. The nurse's goal is to ensure the uterus remains firm to control bleeding, not to relax it.
C. Encourage the client to maintain a semi-Fowler’s position to enhance uterine drainage: Positioning the client with the head of the bed elevated promotes drainage of lochia and exudate from the uterus via gravity, which can help prevent pooling and reduce the risk of ascending infection.
D. Initiate contact precautions: Postpartum endometritis is typically caused by normal flora ascending into the uterus (polymicrobial). It is not transmitted by contact and does not require contact precautions. Standard precautions are sufficient.
E. Instruct the client to wash her hands before and after changing her perineal pad: Crucial hygiene practice to prevent the spread of pathogens from the perineum to the upper reproductive tract and to others. Education on perineal care is always a priority.
F. Obtain a culture specimen of the lochia from the client’s perineal pad using a sterile swab: Obtaining a culture from an already used perineal pad would result in a heavily contaminated and uninformative specimen. Lochia cultures are generally not done routinely because lochia is always contaminated by vaginal and cervical flora. A blood culture is the most appropriate culture to identify the causative organism for endometritis, or an endometrial/intrauterine culture would be taken, but not from the perineal pad.
G. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: This instruction is incorrect and inappropriate. The necessity of stopping breastfeeding depends entirely on the specific antibiotic prescribed. Many antibiotics used to treat postpartum infection (e.g., clindamycin and gentamicin) are compatible with breastfeeding. The nurse should consult the provider and reliable drug resources before advising the client to stop breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The nurse uses gloves when administering an enema: Gloves should always be worn to prevent exposure to body fluids.
B. The nurse positions a client who is postoperative in a semi-fowler's position: This position promotes lung expansion and reduces aspiration risk.
C. The nurse applies a cold compress to reduce localized swelling: Cold compresses reduce swelling and pain from inflammation.
D. The nurse performs auscultation of the lungs without lifting the gown: Auscultation should be performed on bare skin to ensure accurate assessment of breath sounds, as clothing can muffle or distort findings.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Select 1: Administer oxygen at 2 L/min via nasal cannula
Select 2: Administer sublingual nitroglycerin
Rationale for Correct Answer:
Administer oxygen at 2 L/min via nasal cannula: The client is experiencing acute chest pain with shortness of breath and a decrease in oxygen saturation to 92%, indicating potential myocardial ischemia. Providing supplemental oxygen helps improve oxygen delivery to myocardial tissue and prevent further ischemic injury.
Administer sublingual nitroglycerin: Nitroglycerin is indicated for acute chest pain due to suspected acute coronary syndrome (ACS). It works as a vasodilator to reduce myocardial oxygen demand and relieve ischemic pain.
Rationale for Incorrect Answers:
Request a prescription for an increase in statin: Statins are for long-term lipid management and are not an immediate intervention for acute chest pain.
Prepare the client for a cardiac catheterization: While cardiac catheterization may be indicated, it is not the first immediate action before stabilizing the patient.
Check a STAT cardiac troponin: Troponin is important for diagnosis of ACS, but it is not an immediate intervention to relieve ischemia; it is diagnostic.
Request a prescription for a beta-blocker: Beta-blockers reduce myocardial oxygen demand but are not the priority initial action for acute symptomatic ischemia before pain relief and oxygenation.
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