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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.

A.

Initiate contact precautions.

B.

Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr.

C.

Monitor the height and tone of the client's fundus.

D.

Request a prescription for terbutaline from the provider.

E.

Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab,

F.

Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage.

G.

Instruct the client to wash her hands before and after changing her perineal pad.

Answer and Explanation

Correct Answer : C,E,F,G

Rationale:

A. Initiate contact precautions: Endometritis is not typically caused by a pathogen requiring contact precautions (like MRSA or C. difficile). Standard precautions are sufficient unless otherwise indicated.

B. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: The prescribed antibiotics (e.g., clindamycin) are generally considered safe for breastfeeding, and lactation should be encouraged unless specifically contraindicated.

C. Monitor the height and tone of the client's fundus: Fundal tenderness, foul-smelling lochia, and fever are signs of endometritis. Ongoing fundal assessment is important to evaluate uterine involution and identify potential complications like subinvolution or abscess formation.

D. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to relax the uterus in cases of hyperstimulation during labor not for treating uterine infection or postpartum discomfort.

E. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Culturing lochia helps identify the causative organism of the uterine infection and guide antibiotic therapy. This is a standard step in suspected endometritis cases.

F. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Positioning the client with the head elevated allows for better lochia drainage, preventing accumulation that could worsen infection or discomfort.

G. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene helps prevent the spread of infection and supports recovery, especially in the context of suspected endometritis.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices:

  • Serotonin syndrome: The client presents with restlessness, fever, abdominal pain, and disorientation all classic signs of serotonin syndrome. These symptoms developed after a recent dose increase of a serotonergic medication, indicating a likely adverse drug reaction.
  • Adverse effects of paroxetine: Paroxetine, an SSRI, can cause serotonin syndrome, especially when recently increased or combined with other serotonergic agents. The timing of the dose escalation aligns with the emergence of the client’s acute symptoms.

Rationale for Incorrect Choices:

  • Psychosis: While disorientation is present, there is no evidence of hallucinations, delusions, or loss of reality testing, which are essential features of psychosis.
  • Mania: The client does not show signs of elevated mood, grandiosity, pressured speech, or risky behavior, which are typical of mania.
  • Anxiety: Although anxiety is part of the client’s history, the sudden onset of fever and autonomic instability points more clearly to a toxic reaction rather than worsening anxiety.
  • Fluoxetine discontinuation: Fluoxetine has a long half-life, and discontinuation typically causes delayed withdrawal symptoms like dizziness or mood swings not the acute systemic symptoms noted here.

Correct Answer is B

Explanation

Rationale:

A. "You should expect your blisters to last up to three weeks.": Herpes zoster lesions typically last 7 to 10 days, with crusting and healing often occurring within 2 weeks. While some cases may extend slightly longer, stating "up to three weeks" may overgeneralize and mislead.

B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms.": Antiviral drugs like acyclovir or valacyclovir are most effective when initiated within 72 hours of symptom onset. Early treatment reduces severity, duration, and the risk of complications such as postherpetic neuralgia.

C. "People who have had chicken pox are at a decreased risk for herpes zoster.": Herpes zoster occurs due to reactivation of the varicella-zoster virus, which remains dormant after chickenpox. Therefore, individuals who have had chickenpox are actually at increased risk.

D. "Severe pain after the blisters are gone is less common in older adults.": Older adults are more likely to experience postherpetic neuralgia, a complication involving persistent nerve pain after lesions resolve. The risk and severity of this pain increase with age, not decrease.

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