A nurse reviews the provider prescriptions and reassesses the client.
Inform the client she will need to formula feed her newbom until she has received antibiotics for 24 hr.
Request a prescription for terbutaline from the provider.
Monitor the height and tone of the client's fundus.
Instruct the client to wash her hands before and after changing her perineal pad.
Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage.
Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab.
Initiate contact precautions.
Correct Answer : C,D,E,F
Rationale:
A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.
B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.
C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.
D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.
E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.
F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.
G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypotension: Methamphetamines are central nervous system stimulants that typically cause hypertension and tachycardia due to increased sympathetic activity, rather than low blood pressure.
B. Weight loss: Methamphetamines suppress appetite and increase metabolism, which can lead to significant weight loss. This is a common adverse effect associated with chronic use.
C. Somnolence: Stimulant effects of methamphetamines generally cause insomnia and hyperactivity rather than excessive sleepiness. Somnolence is not a typical adverse effect.
D. Lethargy: Methamphetamine use initially produces energy and euphoria. Lethargy may occur only during withdrawal, not as a direct adverse effect of active use.
Correct Answer is B
Explanation
A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.
B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.
C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.
D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.
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