A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?

Rationale:

A. Acrocyanosis: This is a bluish discoloration of the hands and feet that is common in newborns during the first 24 to 48 hours after birth due to immature circulation. It is not a sign of sepsis.

B. Hypertension: Newborns with sepsis are more likely to present with hypotension due to systemic infection and poor perfusion. Hypertension is not typically associated with neonatal sepsis.

C. Rust-stained urine: This discoloration can occur in newborns from urate crystals in the first few days of life and is considered a normal finding, not an indicator of infection.

D. Retractions: Retractions indicate increased work of breathing and respiratory distress, which can occur in newborn sepsis due to systemic infection affecting respiratory function. This is a concerning finding that warrants prompt evaluation.

Rationale for Correct Choice:

• Endometritis: The client's temperature of 38.2°C (100.8°F), foul-smelling lochia, and tender uterus are classic signs of this infection. The high WBC count of 33,000/mm3 further confirms the presence of a significant infection. The client's history of prolonged rupture of membranes and a cesarean section also increases the risk.
• Uterus and lochia assessment: The specific findings of a tender uterus and foul-smelling lochia are the most direct evidence of a uterine infection. The uterus is the primary site of infection in endometritis, and the lochia (postpartum vaginal discharge) reflects the state of the uterine lining.

Rationale for Incorrect Choices:

• Mastitis: While the client reports firm, warm, and tender breasts, mastitis is usually unilateral and accompanied by localized redness and systemic symptoms like fever. In this case, the fever and uterine findings point more toward uterine infection.
• Pneumonia: Lung sounds are clear but diminished; there are no crackles, wheezing, or other respiratory symptoms such as cough or shortness of breath that would indicate pneumonia. The primary infection source appears obstetric, not pulmonary.
• Lung sounds (breath assessment): Diminished breath sounds alone are insufficient to diagnose pneumonia. The client’s main indicators of infection involve the uterus and lochia rather than respiratory compromise.
• Breast and nipple changes: Though mild breast tenderness is noted, these findings do not account for the systemic symptoms and uterine signs, making mastitis less likely as the primary diagnosis.