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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.

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.

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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Correct Answer is B

Explanation

Rationale:

A. "Apply the ointment to the skin every 4 hr.": Nitroglycerin topical ointment is applied every 6 to 8 hours, depending on the provider's instructions. Applying it every 4 hours may increase the risk of side effects such as hypotension or tolerance due to excessive dosing frequency.

B. "Spread the ointment in a thin, even layer.": The medication should be applied in a thin, consistent layer to allow for proper absorption through the skin. The dose is usually measured and spread using applicator paper, avoiding rubbing or massaging it in.

C. "Apply the ointment to the forearm.": The preferred application sites are hairless areas of the chest, back, or upper arms. The forearm is not typically used due to variability in absorption and the presence of thinner skin and more movement.

D. "Massage the ointment into the skin.": Nitroglycerin ointment should never be massaged into the skin. Massaging can lead to unpredictable absorption rates and an increased risk of hypotension or headache due to rapid systemic absorption.

A. Collect 4 mL/kg of blood in a 24-hr period. B. Apply lidocaine cream 30 min prior to collecting the specimen. C. Ask the parents to leave the room prior to collecting the blood specimen. D. Demonstrate the use of the equipment to the child.

Correct Answer is D

Explanation

Rationale:

A. Collect 4 mL/kg of blood in a 24-hr period: This volume exceeds safe limits for blood collection in small children. The guideline is not to exceed 3 mL/kg over 24 hours unless clinically necessary, as excessive draws can lead to anemia or hemodynamic instability.

B. Apply lidocaine cream 30 min prior to collecting the specimen: While lidocaine-prilocaine cream can be helpful, it typically requires at least 60 minutes to achieve adequate dermal analgesia. Applying it for only 30 minutes may not be sufficient to reduce pain effectively.

C. Ask the parents to leave the room prior to collecting the blood specimen: Parents are often a source of comfort and reassurance for preschoolers. Unless their presence is disruptive, involving them in the process can help calm the child and improve cooperation.

D. Demonstrate the use of the equipment to the child: Preschoolers benefit from age-appropriate explanations and demonstrations. Showing them the equipment reduces fear and anxiety by promoting familiarity and a sense of control in an unfamiliar situation.

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for nitroglycerin topical ointment. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is preparing to obtain a blood specimen from a preschooler. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

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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.