A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

Rationale:

• "We should expect the swelling and tingling to worsen before it gets better." This statement needs reinforcement because worsening swelling and tingling can indicate early signs of compartment syndrome. These symptoms are not normal and should prompt immediate medical attention.

• "It is important that our child avoids placing anything inside the cast." This statement reflects understanding because inserting objects inside the cast can break the skin and introduce bacteria, leading to infection. It may also damage the padding and compromise skin protection.
• "We should prop the casted arm on pillows for the next 24 hours." Elevating the limb helps reduce swelling and pain by improving venous return. Keeping the casted arm elevated is a standard part of cast care teaching after an injury.
• "We should notify the provider if the cast becomes loose over time." A loose cast may no longer immobilize the fracture effectively and can allow excessive movement. It may also rub the skin, increasing the risk of irritation or breakdown.
• "We need to be very careful about how we handle the cast for the first 2 days while it dries." This shows understanding because a plaster cast takes 24 to 48 hours to fully dry. Improper handling can cause pressure indentations, leading to skin damage and poor cast integrity.

Rationale for Correct Answers:

1. Condition: Mastitis
Mastitis is an infection of the breast tissue that commonly affects breastfeeding women. It often occurs when bacteria (usually Staphylococcus aureus) enter through a cracked or damaged nipple, allowing pathogens to travel into the milk ducts. Symptoms can start with nipple pain and breast tenderness, progressing to flu-like symptoms, localized redness, and fever if untreated.

2. Evidence: Cracked nipple
The client's report of nipple discomfort throughout feeding and visible crack noted on the left nipple are red flags for potential bacterial entry, placing her at high risk for mastitis. Cracked nipples are common in breastfeeding, especially when there is poor latch or prolonged feeding.

Rationale for Incorrect Options:

Endometritis: This is an infection of the uterine lining. However, this client is 2 weeks postpartum, denies abdominal pain, and has normal lochial progression (whitish-yellow discharge = lochia alba). Her uterus is no longer palpable, indicating appropriate involution. No signs of fever, foul-smelling discharge, or uterine tenderness are noted.

Perineal hematoma: This would present with significant perineal pain, swelling, and possibly bluish discoloration. This client reports only mild perineal discomfort (2/10), likely related to normal healing from her episiotomy.

Group B streptococcus: The client tested negative for Group B Streptococcus. Moreover, GBS is not directly related to cracked nipples or mastitis.

Large for gestational age newborn: While the newborn was indeed LGA, this mainly increases the risk for perineal trauma or shoulder dystocia, not directly mastitis.