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 ["B","C","D","E","F"]
Explanation
A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.
C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.
D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.
E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.
F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.
G. "This medication can increase your blood pressure.":
Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
Correct Answer is A
Explanation
Choice A rationale
Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.
Choice B rationale
While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.
Choice C rationale
Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.
Choice D rationale
Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate