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 A
Explanation
Choice A rationale
Manifestations of shock might not appear until a client loses 20% of their blood volume. This is because the body compensates for blood loss by increasing heart rate and
vasoconstriction, maintaining blood pressure until a significant amount of blood is lost.
Choice B rationale
Hemorrhagic shock will cause a decrease, not an increase, in a client's serum pH due to the accumulation of lactic acid from anaerobic metabolism, leading to metabolic acidosis.
Choice C rationale
The most accurate indication of organ perfusion is a client's urine output. Adequate urine output reflects sufficient renal blood flow and overall perfusion, making it a reliable indicator
of organ perfusion.
Choice D rationale
An infusion of 1 mL of lactated Ringers for each 1 mL of blood loss is not accurate. The typical fluid replacement ratio is 3:, meaning 3 mL of crystalloid solution (like lactated Ringers) is given for each 1 mL of blood loss to account for fluid distribution in the body.
Correct Answer is A
Explanation
Choice A rationale
An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.
Choice B rationale
While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.
Choice C rationale
Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.
Choice D rationale
Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.