A nurse is caring for a client who is 4 days postpartum following a. cesarean birth.

Exhibits

For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.

Each finding may support this more than 1 disease process.

Choice A rationale:

Maintaining the irrigation solution rate is appropriate in this situation. Pink-tinged urine in the drainage bag indicates the presence of blood, which is expected after a transurethral resection of the prostate. However, if the bleeding becomes excessive, the healthcare provider should be notified. Adjusting the irrigation solution rate might be necessary based on the provider's orders, but abruptly changing the rate without medical direction could lead to complications.

Choice B rationale:

Replacing the indwelling urinary catheter is not necessary solely based on the presence of pink-tinged urine. It is essential to assess the patient's overall condition and the extent of bleeding before considering catheter replacement. Catheter replacement without a valid reason can increase the risk of infection and discomfort for the patient.

Choice C rationale:

Performing the Credé's maneuver involves manual compression of the bladder to assist with urine elimination. This maneuver is not indicated in this situation and could potentially cause harm or disrupt the continuous bladder irrigation. It is essential to follow evidence-based practices and avoid interventions that are not appropriate for the patient's condition.

Choice D rationale:

Warming the irrigation solution is not relevant to the situation described. The presence of pink-tinged urine suggests bleeding, which requires careful monitoring and appropriate medical intervention. Warming the solution does not address the underlying cause of the bleeding and should not be the nurse's primary concern in this scenario.

The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.