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 D
Explanation
Rationale:
A. Misoprostol: Misoprostol is a prostaglandin used to stimulate uterine contractions and control postpartum hemorrhage. It is generally safe for clients with hypertension, as it does not cause significant vasoconstriction or elevate blood pressure.
B. Oxytocin: Oxytocin is commonly used to manage postpartum hemorrhage by inducing uterine contractions. It does not have hypertensive effects and is safe for use in clients with a history of high blood pressure.
C. Terbutaline: Terbutaline is a beta-agonist used for tocolysis, not for treating postpartum hemorrhage. Although it may cause tachycardia and hypotension, it is not a uterotonic and is not relevant in this context.
D. Methylergonovine: Methylergonovine is contraindicated in clients with hypertension because it causes intense vasoconstriction, which can significantly elevate blood pressure and increase the risk of stroke or cardiac events in hypertensive clients.
Correct Answer is A
Explanation
Rationale:
A. Sore throat: A sore throat may indicate agranulocytosis, a serious adverse effect of clozapine that results in dangerously low white blood cell counts. Early signs include fever, sore throat, and malaise. This requires immediate reporting and evaluation with a complete blood count.
B. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While bothersome, it is not typically associated with the hematologic or metabolic risks posed by this antipsychotic medication.
C. Rhinitis: Although rhinitis can occur with many medications, it is not a serious or expected side effect of clozapine requiring urgent attention. Mild nasal symptoms are usually self-limiting and not indicative of life-threatening complications.
D. Headache: Headaches are common and nonspecific symptoms that may result from various causes. Unless severe or persistent, they do not typically indicate a dangerous reaction to clozapine and are not prioritized over signs of infection.
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