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. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.
B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.
C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.
D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.
Correct Answer is B
Explanation
Rationale:
A. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.
B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.
C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.
D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.
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