A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following Instructions should the nurse include in the teaching?

Rationale for correct choices:

• Temperature 38.2° C (100.8° F): An elevated temperature in the postpartum period may indicate infection, particularly given the prolonged rupture of membranes and cesarean birth. Early recognition is essential to prevent progression to sepsis.
• Heart rate 104/min: Tachycardia can be an early sign of infection or postpartum hemorrhage. In combination with fever and elevated WBC, this warrants prompt evaluation.
• Client reports feeling unwell: The client’s report of illness is the first indicator of an ongoing disease process which warrants further evaluation, coupled by other findings, this indicates that there is something wrong.
• WBC count 33,000/mm³: This is markedly elevated beyond the normal postpartum range and indicates a possible systemic infection. This finding requires immediate intervention and notification of the provider.
• Fundus boggy but firmed with massage: A boggy uterus suggests uterine atony, which increases the risk of postpartum hemorrhage. Continuous monitoring is needed to prevent excessive blood loss.
• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a sign of endometritis or uterine infection. Early identification and treatment reduce the risk of sepsis and further complications.

Rationale for incorrect choices:

• Vital Signs Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97% on room air: This is within normal limits and does not indicate respiratory compromise at this time. Blood pressure is within normal postpartum range; no immediate intervention is needed. Oxygen saturation is adequate and does not require urgent follow-up.
• Breast firmness with moderate nipple discomfort: These findings are consistent with normal lactation and engorgement, and do not indicate an immediate complication.
• Surgical incision well-approximated with slight edema: Mild edema without redness or drainage is expected postoperatively and does not require immediate intervention.
• No bowel movement since birth, hypoactive bowel sounds: While monitoring is necessary for constipation, this is a common postpartum finding, especially after surgery and opioid use, and does not require urgent intervention.

A. Atrial fibrillation: This dysrhythmia is characterized by an irregularly irregular rhythm with absent or unidentifiable P waves, not a prolonged constant P-R interval.

B. Premature atrial complexes: PACs involve early P waves that may have a normal or slightly different P-R interval, but they do not cause a consistently prolonged P-R interval across all beats.

C. First-degree atrioventricular block: A constant P-R interval greater than 0.20 seconds indicates a first-degree AV block. The atrial impulses are delayed at the AV node, but all impulses are conducted to the ventricles, producing a regular rhythm with prolonged P-R intervals.

D. Complete heart block: In complete heart block (third-degree AV block), there is no relationship between P waves and QRS complexes. The P-R interval is variable, unlike the constant prolongation seen in first-degree AV block.