A nursery nurse is attending the birth of a post-term infant.

Exhibits

Upon review of the medical record, the infant newborn is at risk for developing which of the following symptoms? Select all that apply

Rationale:
A. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: The client exhibits signs of postpartum infection, including foul-smelling lochia, fever, and elevated WBC count. Collecting a culture helps identify the causative organism and guide antibiotic therapy.

B. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing additional pathogens to the uterine or perineal area, supporting infection control and client safety.

C. Initiate contact precautions: Contact precautions are typically used for highly contagious or multidrug-resistant infections. Standard precautions, including hand hygiene, are sufficient for most postpartum infections like endometritis.

D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, reduces uterine stasis, and helps prevent further infection or discomfort.

E. Monitor the height and tone of the client's fundus: Regular assessment of fundal height and tone is essential postpartum to detect uterine atony, retained tissue, or infection. Monitoring ensures early intervention if complications develop.

F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor. There is no indication for its use in this postpartum client with uterine infection.

G. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics, including clindamycin, are compatible with breastfeeding. The client does not need to discontinue breastfeeding unless specifically contraindicated.

Rationale:
A. Diabetes screening: Screening is a form of primary or secondary prevention, aimed at early detection or prevention of disease, rather than tertiary prevention. It helps identify risk factors before complications develop.

B. Family planning: Family planning is a primary prevention strategy, focusing on preventing unintended pregnancies and promoting reproductive health. It does not address the management of existing conditions or complications.

C. Nutrition counseling: Nutrition counseling can serve as primary or secondary prevention depending on context, such as preventing chronic disease or managing early-stage conditions. It is not typically considered tertiary prevention.

D. Physical therapy: Physical therapy is a tertiary prevention intervention because it aims to improve function, reduce complications, and enhance quality of life for clients who already have a health condition. It helps manage existing disease and prevent further disability.