A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?

Rationale:

A. "Morphine 3 mg SQ every 4 hr PRN for pain.": The abbreviation "SQ" is considered unsafe and can be misinterpreted. The Joint Commission recommends avoiding this abbreviation and writing out "subcutaneous" to ensure clarity and patient safety.

B. "Morphine 3.0 mg sub q every 4 hr PRN for pain.": Using a trailing zero (e.g., "3.0 mg") increases the risk of a dosing error if the decimal point is missed. Standard documentation practices recommend omitting trailing zeros for whole numbers.

C. "Morphine 3 mg subcutaneous every 4 hr PRN for pain.": This entry uses the full name "subcutaneous," avoids unsafe abbreviations, and omits the trailing zero, adhering to safe and standardized medication documentation guidelines.

D. "Morphine 3 mg SC q4hr PRN for pain.": Both "SC" and "q4hr" are discouraged abbreviations. "SC" can be confused with "SL" (sublingual), and "q" abbreviations can be misread. Writing terms in full reduces the risk of misinterpretation.

Rationale for Correct Choices:

• Temperature 38.2° C (100.8° F): Although a low-grade fever can occur postpartum, this temperature on day 3 combined with foul-smelling lochia and elevated WBCs raises concern for endometritis. The timing and associated findings shift the significance of this fever from physiologic to potentially infectious.
• Heart rate 104/min: Tachycardia postpartum may result from hypovolemia, infection, or pain. In this context, it supports systemic inflammation or early sepsis when paired with fever, uterine tenderness, and leukocytosis, and should not be dismissed.
• Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding: These symptoms could reflect normal engorgement; however, when combined with systemic signs such as fever and malaise, they may also indicate early mastitis. Continued observation or early intervention may be needed to prevent progression.
• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness, even if the uterus is firm, is an abnormal postpartum finding. It is often associated with endometritis, especially in clients with prolonged rupture of membranes and recent cesarean section.
• Fundus boggy but firmed with massage: A boggy uterus indicates uterine atony, a major cause of postpartum hemorrhage. Though it firmed with massage, its initial softness and the need for stimulation indicate ongoing risk and warrant further monitoring or intervention.
• Moderate amount of dark brown, foul-smelling lochia noted: Foul-smelling lochia is a hallmark of endometritis. The dark color and odor, especially beyond 48 hours postpartum, signal retained products or infection, which need urgent antibiotic treatment and further assessment.
• WBC count 33,000/mm³: A normal postpartum WBC count may rise to 14,000–16,000/mm³, but a value of 33,000/mm³ is markedly elevated. When accompanied by fever, malaise, and abnormal lochia, this strongly suggests infection or developing sepsis requiring immediate follow-up.

Rationale for Incorrect Choices:

• SaO₂ 97% on room air: Oxygen saturation of 97% is expected in a healthy postpartum client and indicates effective oxygen exchange. There is no indication of hypoxia, pulmonary embolism, or sepsis-related respiratory involvement with this reading.
• Surgical incision well approximated with slight edema present; no redness or drainage noted: A healing surgical incision without signs of erythema, discharge, or warmth is a reassuring finding. Mild edema can occur normally and is not indicative of wound infection or dehiscence in this context.
• Hemoglobin 11.1 g/dL (greater than 11 g/dL): Postpartum hemoglobin levels above 11 g/dL suggest the client is not experiencing significant anemia or blood loss. This level supports adequate oxygen-carrying capacity and does not indicate an acute obstetric complication.