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A nurse reviews the provider prescriptions and reassesses the client.

Exhibits

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

Request a prescription for terbutaline from the provider.

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.

Initiate contact precautions.

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.

Answer and Explanation

Correct Answer : E,F,G

A. Request a prescription for terbutaline from the provider. Terbutaline is a tocolytic used to stop preterm labor, not indicated in this postpartum scenario. The client is already on uterotonic therapy (methylergonovine), which is appropriate for postpartum uterine atony.
B. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab is inappropriate because the pad is asceptic.

C. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr. This is incorrect. Breastfeeding is usually safe with most antibiotics, including clindamycin, and mothers with postpartum infections can typically continue breastfeeding unless advised otherwise by the provider.
D. Initiate contact precautions. Contact precautions are not necessary unless the client has an identified or suspected infection that is transmissible by direct contact (e.g., MRSA). Standard precautions are sufficient for routine postpartum care and suspected endometritis.
E. Monitor the height and tone of the client’s fundus. The fundus is tender and was initially boggy, indicating risk for uterine atony or subinvolution. Monitoring tone and height helps detect complications such as hemorrhage or infection.
F. Instruct the client to wash her hands before and after changing her perineal pad. Hand hygiene is essential to prevent the spread of infection to the perineal area or incision and to promote general postpartum hygiene.
G. Encourage the client to maintain a semi-Fowler’s position to enhance uterine drainage. This position helps promote lochia drainage, reduce uterine pooling, and may help with comfort and resolution of infection by improving uterine drainage.

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Correct Answer is B

Explanation

A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.

A. Ketorolac B. Aspirin C. Acetaminophen D. Obuprofen

Correct Answer is C

Explanation

A. Ketorolac. This is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.
B. Aspirin. Aspirin is also an NSAID and can irritate the gastric lining, increasing the risk of ulceration and bleeding. It is contraindicated in clients with peptic ulcers.
C. Acetaminophen. Acetaminophen is the safest option for clients with peptic ulcer disease because it does not affect the gastric mucosa. It provides effective relief for mild to moderate pain, including headaches.
D. Ibuprofen. Like ketorolac and aspirin, ibuprofen is an NSAID and is not recommended for clients with peptic ulcers due to the increased risk of gastrointestinal irritation and bleeding.

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A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

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A nurse reviews the provider prescriptions and reassesses the client.

Exhibits

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