A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

Rationale:

A. Pull the pinna of the infant's ear forward before inserting the probe: For infants, the pinna should be pulled down and back, not forward, to align the ear canal properly for accurate tympanic temperature measurement.

B. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal insertion for infants should be limited to 2.5 cm (1 in) or less to avoid rectal perforation and injury. Inserting 3.8 cm is unsafe.

C. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature measurement is safe and commonly used in infants. Placing the tip in the center of the axilla and holding the arm snugly ensures accurate contact and reading.

D. Insert the oral thermometer in front of the infant's tongue: Infants cannot reliably hold a thermometer under their tongue, making oral measurement inaccurate and unsafe due to risk of swallowing or injury.

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.