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 A
Explanation
Rationale:
A. A health care surrogate (also called a durable power of attorney for health care) is a person designated by the client to make health care decisions if the client becomes incapacitated. This is a key component of advance directives.
B. Advance directives can be revised or revoked by the client at any time as long as they remain competent to do so.
C. Legal counsel is not required to assign a surrogate, though the document typically needs to be witnessed and signed according to state regulations.
D. A DNR order is optional and separate from other parts of an advance directive; clients may choose to include or exclude it.
Correct Answer is C
Explanation
A. Providing educational materials with large print is beneficial for clients who have visual impairments or mild cognitive deficits, but it does not address communication difficulties related to expressive aphasia. Expressive aphasia affects a person’s ability to produce spoken or written language, not their ability to read printed material.
B. A mechanical voice amplifier increases volume but does not help clients who struggle with word finding, sentence formation, or verbal expression. In expressive aphasia (also called Broca’s aphasia), the problem lies in language production, not vocal strength or clarity. Therefore, amplification devices do not improve communication effectiveness.
C. Establishing alternatives to verbal communication—such as using picture boards, communication cards, writing tools, gestures, or electronic devices—allows the client to express needs, emotions, and choices effectively despite verbal limitations. These methods reduce frustration, foster independence, and maintain the client’s participation in decision-making. The nurse should also allow extra time for the client to respond and validate their attempts to communicate.
D. Ensuring that the client’s glasses are available promotes optimal vision, which is important for safety and participation in activities, but it does not directly assist with communication difficulties caused by expressive aphasia. Visual aids may complement communication tools, but the priority action is to provide alternative methods to express language.
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