A nurse on a postpartum unit is caring for a client.

Exhibits

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. (Note: Each column must have at least 1 response option selected)

Rationale:

A. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is not appropriate for infants due to the risk of injury and their inability to hold the thermometer properly. It is generally reserved for children older than 4–5 years.

B. Pull the pinna of the infant's ear forward before inserting the probe: When using a tympanic thermometer for infants under 3 years, the correct method is to pull the pinna down and back, not forward, to straighten the ear canal.

C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is too invasive and risks rectal perforation. For infants, rectal insertion should be only 1.5 to 2.5 cm (0.6–1 in), with extreme caution.

D. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature is the safest and most noninvasive route for infants. Ensuring full skin contact under the center of the axilla provides the most accurate axillary reading.

Rationale:

A. Palpate the pulse distal to the cast: Assessing neurovascular status is the priority immediately after cast application. Palpating the distal pulse helps determine adequate circulation and can detect complications like compartment syndrome early, which can lead to permanent damage if untreated.

B. Position the casted extremity on a pillow: Elevating the extremity helps reduce swelling and pain, but it is a secondary action. Ensuring perfusion through a pulse check takes precedence before supportive comfort measures are initiated.

C. Place an ice pack over the cast: Cold therapy can help minimize swelling and pain in the initial hours after casting, but it should only be done after confirming that circulation is intact. Ice packs should also be used carefully to prevent moisture from damaging the cast.

D. Teach the client to keep the cast clean and dry: Education is important for long-term cast care, but it is not the immediate priority after application. Early assessment for circulation, sensation, and movement must occur first to ensure the cast has not compromised perfusion.