A nurse on a postpartum unit is caring for a client. For each finding, click to specify if the finding is consistent with uterine atony or infection.

Exhibits

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. "Remove a plug from the socket by pulling the cord": Yanking the cord can damage the cord, loosen wiring, and increase the risk of sparks or electrical fire. The correct method is to grasp the plug firmly and pull it straight out to avoid strain on the wire connections.

B. "Use three-pronged grounded plugs": Three-pronged plugs provide a grounding mechanism that reduces the risk of electric shock and fire. Grounded outlets redirect excess electricity safely into the ground if a fault occurs, making them a key part of electrical safety.

C. "Check for a tingling sensation around the cord": A tingling sensation can indicate an electrical short or exposed wiring, which is a serious safety hazard. While it’s important to report and stop using such cords, the focus should be on prevention before such issues arise.

D. "Cover extension cords with a rug": Covering cords with rugs can trap heat, cause insulation to wear down, and increase fire risk. Cords should be left uncovered and positioned to avoid foot traffic while maintaining ventilation to prevent overheating.

Rationale:

A. Pale and a 24-hr fluid deficit of 30 mL: Mild pallor and a small fluid deficit are not uncommon in early stages of illness and may not require immediate intervention. However, more serious signs of dehydration would take priority for reporting.

B. Temperature 38° C (100.4° F) and pulse rate 124/min: These are within expected limits for an infant with mild infection or fever. While they should be monitored, they are not urgent indicators of severe complications from gastroenteritis.

C. Decreased appetite and irritability: These are common symptoms in infants with viral illnesses, including gastroenteritis. Although they affect comfort and feeding, they are not necessarily indicators of serious fluid or electrolyte imbalance.

D. Sunken fontanels and dry mucous membranes: These are clinical signs of moderate to severe dehydration, which is a serious complication of gastroenteritis in infants. These findings must be reported promptly for urgent intervention to prevent further deterioration.