A nurse on a step-down unit is admitting a client.

Exhibits

Drag words from the choices below to fill in each blank in the follow sentence.

The client is at risk for developing

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and

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.

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

Rationale for Correct Choices:

• Temperature 38.2° C (100.8° F): Although a low-grade fever can occur postpartum, this temperature on day 3 combined with foul-smelling lochia and elevated WBCs raises concern for endometritis. The timing and associated findings shift the significance of this fever from physiologic to potentially infectious.
• Heart rate 104/min: Tachycardia postpartum may result from hypovolemia, infection, or pain. In this context, it supports systemic inflammation or early sepsis when paired with fever, uterine tenderness, and leukocytosis, and should not be dismissed.
• Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding: These symptoms could reflect normal engorgement; however, when combined with systemic signs such as fever and malaise, they may also indicate early mastitis. Continued observation or early intervention may be needed to prevent progression.
• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness, even if the uterus is firm, is an abnormal postpartum finding. It is often associated with endometritis, especially in clients with prolonged rupture of membranes and recent cesarean section.
• Fundus boggy but firmed with massage: A boggy uterus indicates uterine atony, a major cause of postpartum hemorrhage. Though it firmed with massage, its initial softness and the need for stimulation indicate ongoing risk and warrant further monitoring or intervention.
• Moderate amount of dark brown, foul-smelling lochia noted: Foul-smelling lochia is a hallmark of endometritis. The dark color and odor, especially beyond 48 hours postpartum, signal retained products or infection, which need urgent antibiotic treatment and further assessment.
• WBC count 33,000/mm³: A normal postpartum WBC count may rise to 14,000–16,000/mm³, but a value of 33,000/mm³ is markedly elevated. When accompanied by fever, malaise, and abnormal lochia, this strongly suggests infection or developing sepsis requiring immediate follow-up.

Rationale for Incorrect Choices:

• SaO₂ 97% on room air: Oxygen saturation of 97% is expected in a healthy postpartum client and indicates effective oxygen exchange. There is no indication of hypoxia, pulmonary embolism, or sepsis-related respiratory involvement with this reading.
• Surgical incision well approximated with slight edema present; no redness or drainage noted: A healing surgical incision without signs of erythema, discharge, or warmth is a reassuring finding. Mild edema can occur normally and is not indicative of wound infection or dehiscence in this context.
• Hemoglobin 11.1 g/dL (greater than 11 g/dL): Postpartum hemoglobin levels above 11 g/dL suggest the client is not experiencing significant anemia or blood loss. This level supports adequate oxygen-carrying capacity and does not indicate an acute obstetric complication.