A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?

Rationale:
A. Remove the restraints from the client: Restraints should be discontinued as soon as the client no longer poses a danger to themselves or others. Prompt removal prevents unnecessary restriction and respects the client’s rights and dignity.

B. Offer the client PRN pain medication: While assessing for discomfort is important, pain medication is not the immediate priority once the client is calm and cooperative, unless the client requests it or shows signs of pain.

C. Continue to monitor the client every 15 min: Monitoring should continue after restraint removal according to facility policy, but the first action is to remove the restraints to avoid unnecessary confinement.

D. Encourage the client to attend a group therapy session: While therapeutic activities are important, this is not the immediate action following restraint use. Ensuring the client’s safety and removing restraints takes priority.

Rationale for Correct Findings:

• Temperature 38.2° C (100.8° F): Fever in a postpartum client may indicate infection such as endometritis, mastitis, or wound infection. Early detection is essential to prevent progression to sepsis, especially after cesarean birth and prolonged rupture of membranes.

• Heart rate 104/min: Tachycardia in the postpartum period may reflect infection, pain, or hypovolemia. Coupled with fever and leukocytosis, it indicates systemic inflammatory response requiring urgent evaluation.

• Client reports feeling unwell: Subjective complaints of malaise can be an early indicator of infection or postpartum complications. When combined with objective findings like fever and elevated WBC, it requires prompt follow-up.

• WBC count 33,000/mm³: Significantly elevated leukocytes indicate a severe inflammatory or infectious process. Immediate assessment and intervention are necessary to prevent progression to sepsis.

• Uterus firm at 1 cm above the umbilicus and tender to palpation; fundus boggy but firmed with massage: A boggy fundus and uterine tenderness can indicate uterine atony or early postpartum infection. These findings, especially with elevated temperature and WBC, require urgent monitoring and intervention.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is abnormal and may signal endometritis, particularly after cesarean delivery and prolonged rupture of membranes. This requires prompt evaluation and potential initiation of antibiotics.

Rationale for Incorrect Findings:

• Breasts firm, heavy, and warm with moderate nipple discomfort while breastfeeding: These are expected findings related to milk engorgement. They are typical postpartum changes and can be managed with frequent breastfeeding or expressing milk.

• Surgical incision well approximated with slight edema, no redness or drainage: Slight edema at the incision site is normal post-cesarean. Absence of redness, warmth, or drainage indicates no infection requiring urgent intervention.

• BP 108/70 mm Hg: Blood pressure is within the acceptable range for a postpartum client and does not indicate immediate concern.

• Respiratory rate 18/min: This is within normal limits for an adult and does not require urgent intervention.

• SaO2 97% on room air: Oxygen saturation is within normal range and indicates adequate oxygenation, not requiring immediate follow-up.

• Hemoglobin 11.1 g/dL: This value is within normal postpartum limits, indicating no acute anemia or need for immediate intervention.