The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Rationale for Correct Choices

• Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
• Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.

Rationale for Incorrect Choices

• Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
• Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
• Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.

Rationale:

A. Administer the medication as prescribed: Administering amoxicillin to a client with a penicillin allergy can result in serious allergic reactions, including rash, hives, or anaphylaxis. Amoxicillin is a penicillin derivative, it is contraindicated in patients with penicillin allergies.

B. Discuss the prescription with the health care provider: The nurse must clarify potentially harmful prescriptions directly with the provider. This ensures patient safety by verifying if the medication should be changed, considering the client’s documented allergy to penicillin.

C. Call the pharmacist for clarification of the medication contraindications: While pharmacists can verify drug classes and potential reactions, they do not have the authority to discontinue or modify a prescription. Only the healthcare provider can make necessary changes to an order.

D. Place an incident report in the medical record: Incident reports are meant for internal documentation and are never placed in the client’s medical record. Since the error has not occurred yet, prevention through provider consultation is the priority action.