A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

Rationale:

A. A client who is 4 hr postpartum and has a heart rate of 90/min: A heart rate of 90/min is within normal postpartum limits. This client is stable and does not require immediate assessment, making them a lower priority compared to clients showing signs of possible infection or complications.

B. A client who is 4 days postpartum and has a WBC count of 18,000/mm³ (5,000 to 10,000/mm³): An elevated WBC count 4 days postpartum can indicate a serious infection, such as endometritis or another postpartum infection. This client is at risk for rapid deterioration and requires immediate assessment and intervention.

C. A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F): A mild temperature elevation shortly after birth can be expected due to normal postpartum physiologic changes. While it should be monitored, it is not as urgent as the markedly elevated WBC count indicating potential infection.

D. A client who is 2 days postpartum and reports dysuria: Dysuria may indicate a urinary tract infection, which requires evaluation, but this is less immediately threatening than a client with signs of systemic infection. This client should be assessed after clients with potential severe infection or hemodynamic instability.

Rationale:

A. "Biofeedback requires concentration to control physiological responses.": Biofeedback is a technique that helps clients gain voluntary control over involuntary bodily functions, such as muscle tension, heart rate, or skin temperature. Through focused concentration and real-time feedback from monitoring devices, clients learn to reduce stress and prevent migraine triggers.

B. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation.": This description aligns more with massage or energy-based therapies, not biofeedback. Biofeedback does not involve physical manipulation of tissues but relies on monitoring and controlling physiological responses through mental focus.

C. "Biofeedback uses herbs to reduce inflammation": Herbal therapy is a complementary approach unrelated to biofeedback. Biofeedback does not incorporate herbal remedies and instead emphasizes self-regulation techniques using bio-monitoring equipment.

D. “Biofeedback stimulates certain pressure points to relax muscles": Stimulating pressure points is characteristic of acupressure or acupuncture, not biofeedback. While muscle relaxation is a goal of biofeedback, it is achieved through self-regulation and feedback, not external stimulation.