Exhibits

Click to highlight the findings that indicate an improvement in the client’s condition

Laboratory Results

1800:

• WBC count 6,700/mm3 (5,000 to 10,000/mm3)
• Hemoglobin 12 g/dL (14 to 18 g/dL)
• Hematocrit 36% (40% to 52%)

Vital Signs

1800:

• Blood pressure 112/74 mm Hg
• Heart rate 95/min
• Respiratory rate 18
• Temperature 37.5(99.5° F)

A. Cleanse the insertion site of the drain using a circular motion toward the center: Proper technique involves cleaning from the least contaminated area (the center) outward to the surrounding skin, not toward the center, to prevent introducing pathogens into the wound.

B. Irrigate the wound with a low-pressure flow of solution: Low-pressure irrigation helps remove debris and exudate without damaging tissue or disrupting healing. It is a safe and effective method for cleansing an abdominal incision.

C. Irrigate the wound using a 10-mL syringe: Using a small syringe can create high-pressure flow, which may traumatize tissue. Larger volume syringes (e.g., 30–60 mL) with controlled, low-pressure flow are recommended for wound irrigation.

D. Cleanse the wound starting at the bottom and moving upward: Wound cleaning should proceed from the least contaminated area (top or center of the incision) toward more contaminated areas (periphery) to reduce the risk of introducing bacteria into the wound.

Rationale for Correct Choices:

• Macrosomia: Post-term infants (≥ 42 weeks) are at higher risk of excessive birth weight due to prolonged nutrient exposure in utero. Larger infants are prone to birth trauma, shoulder dystocia, and hypoglycemia after delivery.

• Meconium aspiration syndrome: Thick green amniotic fluid indicates meconium passage in utero, likely due to fetal stress from prolonged labor and late decelerations. Inhalation of meconium-stained fluid at birth can cause airway obstruction, chemical pneumonitis, and respiratory distress.

Rationale for Incorrect Choices:

• Bronchopulmonary dysplasia: This chronic lung disease is typically a complication in premature infants requiring prolonged mechanical ventilation and high oxygen concentrations, not in post-term newborns.

• Intraventricular haemorrhage: This complication is primarily seen in premature infants with fragile germinal matrix vessels; it is uncommon in term or post-term neonates unless there is severe birth trauma or asphyxia.