A nurse is caring for a client who is 3 days postpartum in the postpartum unit.
History and Physical: A 30-year-old female client had a vaginal birth 3 days ago with prolonged rupture of membranes. Internal fetal monitoring was used during labor. The client has been experiencing fever, chills, and abdominal pain. She has a history of gestational diabetes and hypertension.
Nurses Notes: The client reports feeling weak and fatigued. She has been having difficulty breastfeeding and feels engorged. The lochia is malodorous and heavy. She complains of a headache and dizziness. The client has been crying frequently and expresses feeling overwhelmed. She also mentions that she has not been able to sleep well since delivery.
Vital Signs:
Temperature: 38.5°C (101.3°F)
Pulse: 110 bpm
Respiratory rate: 24 breaths per minute
Blood pressure: 140/90 mmHg
Oxygen saturation: 98% on room air
Physical Examination Results:
The client appears pale and diaphoretic. Her breasts are tender and engorged with signs of erythema. The abdomen is soft but tender to palpation, especially in the lower quadrants. The fundus is boggy and located above the umbilicus. Lochia is heavy and malodorous. There is mild pedal edema noted in both lower extremities.
Querry:A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client.)
Obtain a prescription for a broad-spectrum antibiotic.
Initiate airborne isolation precautions.
Place the client on strict bedrest.
Instruct the client to stop breastfeeding.
The Correct Answer is A
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.
-
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.
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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.
Choice B rationale
Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.
Choice C rationale
Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.
Choice D rationale
Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.
Correct Answer is C
Explanation
Choice A rationale
Gaining 2 pounds per week throughout the rest of pregnancy is excessive and not recommended. Normal weight gain is approximately 1 pound per week in the second and third trimesters.
Choice B rationale
Dieting during pregnancy can lead to inadequate nutrient intake for both the mother and the developing fetus. It is essential to focus on a balanced diet rather than trying to lose weight.
Choice C rationale
Meeting with a dietitian can help the client assess their nutritional needs and develop a healthy eating plan to support their pregnancy, ensuring both maternal and fetal health.
Choice D rationale
Eating an additional 700 calories per day is too high. Generally, an additional 300-500 calories per day is recommended during the second and third trimesters to support pregnancy.