A nurse is monitoring a client following the insertion of a peripheral intravenous catheter. Which of the following findings should indicate to the nurse that the client is experiencing phlebitis at the insertion site?

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

Rationale:

A. "Playing music will increase my husband's alertness.": Music therapy is not primarily used to increase alertness in hospice clients. Soothing music may promote relaxation and even drowsiness, especially in clients receiving sedating medications for or end-of-life comfort.

B. "I will discontinue music therapy when my husband is no longer responsive": Music therapy can still provide comfort even when a client is unresponsive. Familiar or calming music may have soothing effects and contribute to emotional peace, making it appropriate throughout all stages of hospice care.

C. "My husband won't need medication for breakthrough pain while using music therapy.": Music therapy is a complementary technique, not a replacement for pharmacologic pain management. Clients may still require medications for breakthrough pain.

D. "Music will distract my husband's awareness of the pain.": Music therapy helps reduce the perception of pain by providing sensory distraction and promoting relaxation. This cognitive diversion is one of the key benefits of using music as part of holistic pain management in hospice care.