A nurse in an acute care facility is caring for a toddler.

 

Exhibits

For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

Rationale for Correct Choices:

• Intravenous antibiotic: The client is exhibiting signs of postpartum endometritis, including fever, tachycardia, a boggy and tender uterus, and foul-smelling lochia. IV antibiotics are the standard treatment to rapidly address bacterial infection and prevent systemic complications.
• Increase in daily fluid intake: Adequate hydration supports the client’s recovery by improving perfusion to the uterus, aiding in the clearance of infection, and preventing dehydration, especially if the client is febrile or breastfeeding.

Rationale for Incorrect Choices:

• Intrauterine tamponade balloon: This intervention is used primarily for severe postpartum hemorrhage, which is not evident in this client. Vital signs and lochia amount do not indicate ongoing hemorrhage.
• Kleihauer-Betke test: This test identifies fetal-maternal hemorrhage, which is not relevant to postpartum infection management. The client’s presentation suggests infection rather than blood loss.
• Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not a concern for a postpartum client. The client’s symptoms are consistent with infection rather than uterine contractions needing suppression.

Rationale:

A. Abdominal pain: While abdominal pain can occur with peritonitis, it often develops after the initial changes in the dialysate effluent. Pain may also be related to catheter placement or dialysate temperature, so it is not the earliest definitive indicator.

B. Cloudy effluent: Cloudy dialysate is typically the first and most reliable sign of peritonitis in clients receiving peritoneal dialysis. It indicates the presence of white blood cells and infection in the peritoneal cavity before systemic symptoms appear.

C. Nausea: Nausea may occur later as part of the systemic inflammatory response, but it is nonspecific and can be caused by multiple factors, including the dialysis process itself or other gastrointestinal disturbances.

D. Fever: Fever is a later manifestation of peritonitis, often developing after local signs are present. It indicates systemic involvement and immune activation but is not the earliest detectable change.