Exhibits

Select the 3 findings that require immediate follow-up by the nurse.

Rationale for Correct Options:

• Placental abruption: This condition involves the premature detachment of the placenta from the uterine wall, often triggered by hypertensive disorders. The client’s elevated blood pressure (148/94 mm Hg), facial edema, and hyperreflexia point toward preeclampsia, a leading risk factor for placental abruption.
• Hypertension: Hypertension during pregnancy compromises uteroplacental blood flow, potentially causing vascular damage and leading to placental separation. The client’s reading reflects stage 1 hypertension, which, along with other signs, raises concern for placental complications such as abruption.

Rationale for Incorrect Options:

• Spontaneous abortion: Typically occurs before 20 weeks gestation, making it irrelevant for a client at 30 weeks. There are no signs of fetal loss or cervical dilation in this case.
• Placenta previa: Presents with painless vaginal bleeding in the second or third trimester. This client has no vaginal bleeding or placental misplacement.
• Chorioamnionitis: This infection would present with fever, uterine tenderness, and fetal tachycardia. The client is afebrile, has clear lung sounds, and shows no evidence of intrauterine infection.
• Oligohydramnios: Usually detected via ultrasound or significantly low fundal height. The client's fundal measurement (29 cm at 30 weeks) is appropriate, and there’s no mention of decreased amniotic fluid.
• Hyperreflexia: Although suggestive of preeclampsia, it is a secondary symptom that indicates neurologic involvement and seizure risk rather than directly causing placental abruption.
• Vomiting: While it may be associated with preeclampsia, it is non-specific and does not independently increase the risk of placental abruption without supporting findings like hypertension or abdominal pain.

A. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene is essential in preventing the spread or worsening of infection, especially when endometritis is suspected.
B. Initiate contact precautions: Contact precautions are not necessary for endometritis, which is not a contagious condition. Standard precautions are sufficient.
C. Monitor the height and tone of the client's fundus: Fundal assessment is important to detect uterine atony and evaluate the response to methylergonovine, which is prescribed to improve uterine tone and reduce postpartum bleeding.
D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: This position promotes lochial drainage and prevents pooling of infected discharge in the uterine cavity, supporting infection resolution.
E. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used for postpartum infections, including clindamycin, are compatible with breastfeeding. Breastfeeding is usually encouraged unless contraindicated.
F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to relax the uterus in preterm labor, not to treat postpartum infection or improve uterine tone. Methylergonovine is already prescribed for uterine tone enhancement.
G. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Cultures from a perineal pad may be contaminated. If needed, endometrial cultures are obtained using a sterile technique via the cervix.