A nurse is caring for a 9-year-old child at a clinic.

Exhibits

The nurse should determine that the assessment findings are consistent with which of the following conditions?
For each potential condition, click to specify if the assessment findings are consistent with a sprain, a fracture, or a dislocation. Each finding may support more than 1 condition.

Rationale for Correct Findings:

• Temperature 38.2° C (100.8° F): Fever in a postpartum client may indicate infection such as endometritis, mastitis, or wound infection. Early detection is essential to prevent progression to sepsis, especially after cesarean birth and prolonged rupture of membranes.

• Heart rate 104/min: Tachycardia in the postpartum period may reflect infection, pain, or hypovolemia. Coupled with fever and leukocytosis, it indicates systemic inflammatory response requiring urgent evaluation.

• Client reports feeling unwell: Subjective complaints of malaise can be an early indicator of infection or postpartum complications. When combined with objective findings like fever and elevated WBC, it requires prompt follow-up.

• WBC count 33,000/mm³: Significantly elevated leukocytes indicate a severe inflammatory or infectious process. Immediate assessment and intervention are necessary to prevent progression to sepsis.

• Uterus firm at 1 cm above the umbilicus and tender to palpation; fundus boggy but firmed with massage: A boggy fundus and uterine tenderness can indicate uterine atony or early postpartum infection. These findings, especially with elevated temperature and WBC, require urgent monitoring and intervention.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is abnormal and may signal endometritis, particularly after cesarean delivery and prolonged rupture of membranes. This requires prompt evaluation and potential initiation of antibiotics.

Rationale for Incorrect Findings:

• Breasts firm, heavy, and warm with moderate nipple discomfort while breastfeeding: These are expected findings related to milk engorgement. They are typical postpartum changes and can be managed with frequent breastfeeding or expressing milk.

• Surgical incision well approximated with slight edema, no redness or drainage: Slight edema at the incision site is normal post-cesarean. Absence of redness, warmth, or drainage indicates no infection requiring urgent intervention.

• BP 108/70 mm Hg: Blood pressure is within the acceptable range for a postpartum client and does not indicate immediate concern.

• Respiratory rate 18/min: This is within normal limits for an adult and does not require urgent intervention.

• SaO2 97% on room air: Oxygen saturation is within normal range and indicates adequate oxygenation, not requiring immediate follow-up.

• Hemoglobin 11.1 g/dL: This value is within normal postpartum limits, indicating no acute anemia or need for immediate intervention.

Rationale:
A. Serum albumin: Serum albumin is a key indicator of a client’s nutritional status, particularly protein intake and synthesis. Low albumin levels can reflect malnutrition, chronic illness, or liver dysfunction, while normal levels suggest adequate nutritional support and protein reserves.

B. Troponin level: Troponin is a cardiac biomarker used to diagnose myocardial injury or infarction. It is not related to nutrition and does not provide any information about the client’s dietary intake or protein status.

C. Serum sodium: Serum sodium reflects fluid and electrolyte balance rather than nutritional status. Abnormal sodium levels are typically associated with dehydration, fluid overload, or endocrine disorders, not with protein or calorie malnutrition.

D. Erythrocyte sedimentation rate: The erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and infection. It may rise with inflammatory conditions but does not provide direct information about a client’s nutritional health.