A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?
Elevate the head of the client's bed.
Administer a dose of terbutaline.
Initiate oxygen at 2 L/min via nasal cannula.
Initiate an infusion of oxytocin.
The Correct Answer is D
Choice A rationale
Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.
Choice B rationale
Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.
Choice C rationale
Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.
Choice D rationale
Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.
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Correct Answer is A
Explanation
A. Obtain a prescription for a broad-spectrum antibiotic.
The client's fever (38.5°C), chills, abdominal pain, malodorous lochia, and tender fundus suggest a potential postpartum infection, such as endometritis. Administering a broad-spectrum antibiotic is necessary to treat the infection. Given the clinical scenario, the nurse should prioritize addressing the client's symptoms and signs that suggest infection and support her well-being postpartum. Here's a breakdown of the appropriate actions:
B. Initiate airborne isolation precautions.
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Not necessary in this case. The client's symptoms and signs do not suggest an airborne infectious disease.
C. Place the client on strict bedrest.
-
This is not necessary. While rest is important, strict bedrest may not be required and could increase the risk of other complications, such as deep vein thrombosis (DVT).
D. Instruct the client to stop breastfeeding.
-
Not necessary unless there is a specific contraindication. Instead, the nurse can provide support and advice on managing engorgement and breastfeeding difficulties.
Correct Answer is D
Explanation
Choice A rationale
Starting each feeding with the most sore breast can worsen the condition, as the infant initially sucks more vigorously at the beginning of a feeding. This might increase the pain and damage to the already sore breast.
Choice B rationale
Moisture-proof lining in breast pads can cause an accumulation of moisture, creating a breeding ground for bacteria. This can exacerbate soreness and lead to infections such as mastitis.
Choice C rationale
Breastfeeding less frequently can lead to engorgement and plugged ducts, which can further complicate breast soreness and potentially decrease milk supply. Regular feeding helps in maintaining milk flow and production.
Choice D rationale
Colostrum has natural healing properties, including immunoglobulins and growth factors, that can help heal sore and cracked nipples. Applying colostrum can promote faster recovery and reduce discomfort.