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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 D

Explanation

Rationale:

A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.

B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.

C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.

D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.

A. Instruct the parent to give 5 mcg of vitamin D daily. B. Instruct the parent to give the infant water every 3 hr between feedings. C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age. D. Recommend the parent mix the milk with rice cereal for feedings.

Correct Answer is C

Explanation

Rationale:

A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.

B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.

C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.

D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.

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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.