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A nurse on a postpartum unit is caring for a client.

Exhibits
The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply

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.

Answer and Explanation

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.

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Correct Answer is ["A","C","D","I"]

Explanation

A. Perform daily weights: Daily weights are important to monitor progress and detect fluid or nutritional changes. This routine, non-invasive task is appropriate for delegation to assistive personnel (AP) under nurse supervision.

B. Identify thoughts that reinforce disordered eating patterns: Requires therapeutic communication and assessment, which are nursing responsibilities. Not appropriate for delegation to AP.

C. Accompany the client to the restroom following meals: Clients with bulimia are at risk of vomiting or purging after eating. Having an AP accompany the client helps prevent self-induced vomiting and ensures compliance with the treatment plan. The AP should report any unusual behavior to the nurse.

D. Observe the client during meals: Monitoring during meals ensures the client eats appropriately and avoids concealing or discarding food. This is a behavioral safety measure that can be delegated, while the nurse focuses on therapeutic interventions.

E. Consult the dietitian to determine the client’s caloric intake: Consulting other team members is a nursing role, involving coordination of interdisciplinary care.

F. Use cognitive behavioral techniques to address the client’s behavior: CBT and psychotherapy require specialized knowledge and are conducted by nurses or mental health professionals, not assistive personnel.

G. Discuss measures to assist the client to develop a positive body image: Involves therapeutic communication and counseling, not within the AP’s scope.

H. Encourage the client to discuss feelings of new eating patterns: Addressing emotions and behavioral change is a therapeutic intervention requiring nursing judgment.

I. Check the client’s vital signs: Vital signs provide data about orthostatic hypotension, dehydration, or arrhythmia risk. The AP can collect this data, while the nurse evaluates and interprets the results.

A. After inflation, deflate a blood pressure cuff on the client’s arm while palpating their brachial pulse. B. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min. C. Measure the client's apical pulse while another nurse measures their radial pulse. D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations.

Correct Answer is C

Explanation

A. This describes blood pressure measurement, not pulse deficit assessment.

B. Comparing carotid pulses in different positions is used to assess for orthostatic changes, not pulse deficit.

C. A pulse deficit is the difference between the apical pulse (central) and radial pulse (peripheral). This measurement helps identify conditions like atrial fibrillation where some heartbeats fail to produce peripheral perfusion.

D. Assessing both radial pulses simultaneously checks for pulse equality between limbs, not for pulse deficit.

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A nurse on a postpartum unit is caring for a client.

Exhibits
The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply