A nurse is caring for a client who is scheduled for surgery. The client states, "I have decided not to have the surgery." Which of the following responses should the nurse make to the client?

Rationale for Correct Answers:

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
• Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
• Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
• WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

• Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
• Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning

Rationale:

A. Position the child at a 10° to 20° angle after feeding: This angle is too low to effectively reduce the risk of aspiration. The child should remain in at least a 30° to 45° upright position during and after feeding for optimal safety.

B. Measure the tubing from the nose to the distal port: Correct placement measurement involves determining the appropriate tube length from the tip of the nose to the earlobe and then to the xiphoid process. Measuring to the distal port ensures accurate placement for safe feeding.

C. Warm the formula in the microwave: Microwaving can create uneven heating and hot spots that may burn the gastrointestinal mucosa. Formula should be warmed by placing the container in warm water and checking the temperature before administration.

D. Complete the feeding in 5 min: Rapid feeding increases the risk of nausea, vomiting, and aspiration. Feedings should be administered slowly over the recommended time frame to allow for tolerance and digestion.