A nurse reviews the provider prescriptions and reassesses the client.
Initiate contact precautions.
Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr.
Monitor the height and tone of the client's fundus.
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,
Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage.
Instruct the client to wash her hands before and after changing her perineal pad.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Ask an experienced nurse to assist with the procedure: Seeking guidance from an experienced nurse supports safe practice and skill development. It ensures the procedure is performed correctly while providing an opportunity for supervised learning, which is appropriate for a newly licensed nurse.
B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires the clinical judgment and skills of a registered nurse. It should not be delegated to assistive personnel who are not trained or licensed to perform such procedures.
C. Refuse to take the assignment: Refusing the assignment without attempting to seek help or learn is not a constructive or professional approach. Nurses are expected to seek support when performing unfamiliar but appropriate tasks within their role.
D. Identify that the task is in the scope of RN practice and perform the suctioning: While it is within the RN scope, performing a skill without training or supervision may compromise patient safety. Competence must be demonstrated or developed with supervision before performing independently.
Correct Answer is D
Explanation
Rationale:
A. Compare a list of common medications to treat a condition to the actual prescriptions: This approach does not meet the definition of medication reconciliation, which focuses on comparing the client’s actual prior medications to new orders to prevent errors.
B. Compare the prescription to the allergy history of the client: While this is an important safety check, it is not the primary purpose of medication reconciliation. Allergy review is a separate step done for every prescribed medication, not specifically during reconciliation.
C. Compare the medication label to the provider's prescription on three occasions before administration: This is part of the "three checks" of medication administration to ensure accuracy and safety, but it is unrelated to the reconciliation process that occurs during admission, transfer, or discharge.
D. Compare the client's list of home medications to the admission prescriptions written for the client: This is the central process in medication reconciliation. It ensures continuity of care, prevents omissions, duplications, or interactions, and identifies changes that need clarification.
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