A nurse is assessing a client who is postpartum and has developed endometritis.
Which of the following findings should the nurse expect?

Choice A rationale

Chills are a systemic manifestation of an infectious process and are commonly associated with endometritis. Endometritis is an infection of the uterine lining, which can cause a systemic inflammatory response. This response often includes fever and chills, as the body's immune system fights the invading pathogens, causing a thermoregulatory cascade. A temperature of 100.4°F (38°C) or higher is typical.

Choice B rationale

Back pain can occur with various postpartum conditions, but it is not a primary or specific finding for endometritis. While uterine cramping and pelvic pain are characteristic due to the uterine inflammation, back pain is not as specific. More classic signs are fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia due to the presence of bacteria.

Choice C rationale

Tachycardia, not bradycardia, is an expected finding in a client with endometritis. Tachycardia is a physiological response to fever, infection, and the systemic inflammatory process. The heart rate increases to compensate for increased metabolic demand and to circulate immune cells more efficiently. Bradycardia would be an unusual and unexpected finding.

Choice D rationale

Agitation is not a primary or typical finding of endometritis. Endometritis is a physical infection of the uterine lining. While discomfort and fever may cause irritability, agitation is not a specific expected symptom. This finding is more associated with neurological or psychiatric conditions, or severe complications like septic shock, which is a more advanced state. *.

Choice A rationale

Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.

Choice B rationale

Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.

Choice C rationale

Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.

Choice D rationale

Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.