Question

A nurse is caring for a client who is 3 days condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Exhibit 1
Medical History
Gravida 1, Para 138 weeks of gestationForceps-assisted birth following failed vacuum-assisted attempt.3rd degree laceration with a repairAmniotic membranes ruptured for 18 hr prior to delivery.Pregnancy complicated by gestational diabetes and anemia.

Exhibit 2
Vital Signs
Temperature 38.3° C (101° F)Heart rate 104/minRespiratory rate 20/minBlood pressure 108/70 mm Hg

Exhibit 3
Nurses' Notes
Client states "I feel terrible today. I have this feeling of pain and pressure in my pelvis." Client reports general malaise and chills. Uterus firm at the umbilicus and tender to palpation. Moderate amount of dark foul-smelling lochia noted. Generalized perineal edema observed. Frequently voiding large amounts of urine. Client reports an abdominal pain level of 5 on a scale of 0 to 10.

Exhibit 4
Diagnostic Results
Hemoglobin 10 mg/dL (12 to 16 mg/dL, pregnant > 11 g/dL)Hematocrit 37% (37 to 47%, pregnant > 33%)WBC count 37,000/mm3 (5,000 to 10,000 mm3​)

Answer 1

The client likely has a postpartum infection such as endometritis. The nurse should initiate antibiotics, assess temperature and fundal height, monitor WBC count, and observe lochia. Vital signs and lochia characteristics are essential to monitor progress.

Step-by-step explanation:

Postpartum Infection and Management

The client is exhibiting signs indicative of a postpartum infection, such as increased temperature, tachycardia, and foul-smelling lochia. This condition is likely endometritis, an infection of the uterine lining.

To address this condition, the nurse should first initiate broad-spectrum antibiotics as prescribed and regularly assess the patient's temperature and fundal height to monitor for symptoms of infection and uterine involution. Monitoring white blood cell count (WBC) and ensuring adequate hydration are paramount.

For ongoing assessment of the client's progress, the nurse should monitor vital signs, particularly temperature and heart rate, and observe the characteristics of lochia for changes in amount, color, and odor.