A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Yellow-green drainage from a surgical incision may indicate the presence of infection, especially if the drainage is purulent. This finding should be reported to the provider promptly for further evaluation and management to prevent complications such as wound infection or dehiscence.

A. Yellow-green drainage on the surgical incision: Yellow-green drainage suggests the presence of infection, which is a concerning finding in a postoperative client. It may indicate purulent drainage, which requires further assessment and possibly treatment with antibiotics.
B. Blood pressure 102/66 mm Hg: A blood pressure of 102/66 mm Hg is within the normal range for an adult client and does not typically require immediate intervention. However, trends in blood pressure should be monitored, especially if the client is symptomatic or if there are significant changes from the client's baseline.
C. Straw-colored urine from an indwelling urinary catheter: Straw-colored urine is a normal finding and indicates adequate hydration and kidney function. As long as the urine output is adequate and there are no other signs of urinary tract issues, this finding does not typically require immediate reporting.
D. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute is within the normal range for an adult client and does not typically require immediate intervention. However, it's important to assess the client's respiratory status comprehensively, including oxygen saturation and lung sounds, to ensure adequate ventilation.

A. Black-colored stools: Black-colored stools are not an expected side effect of IV rifampin. Black stools can result from gastrointestinal bleeding or the consumption of certain foods or medications, but they are not directly related to rifampin administration.
B. Staining of teeth: Staining of teeth, often described as orange or red discoloration, is a well-known side effect of rifampin when taken orally. However, this side effect is typically associated with long-term oral use rather than IV administration. IV rifampin is not expected to cause staining of teeth.
C. Red-colored urine: Rifampin can cause red-orange discoloration of bodily fluids, including urine, sweat, saliva, and tears. This phenomenon is harmless and reversible but can be alarming to patients. It is important to educate clients about this potential side effect to alleviate concerns.
D. Constipation: Constipation is not a common side effect of rifampin. While gastrointestinal disturbances such as nausea, vomiting, and diarrhea can occur with rifampin therapy, constipation is not typically reported. If a client experiences persistent constipation while taking rifampin, other factors should be considered and evaluated.