The nurse continues to care for the client

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Rationale for Correct Choices:

• Pneumonia: Postoperative pediatric patients are at risk for pneumonia due to impaired lung expansion from pain, shallow breathing, and immobility. The child's shallow respirations, refusal to use the incentive spirometer, and diminishing breath sounds at the bases point to impaired alveolar ventilation, which increases risk for atelectasis and subsequent pneumonia.
• Shallow breathing: Persistent shallow respirations prevent full lung expansion, allowing mucus and secretions to pool in the alveoli. This stagnation reduces oxygenation and creates a favorable environment for pathogens, contributing to pneumonia development. Pain and sedation may also contribute to this breathing pattern.
• Lack of incentive spirometer use: Incentive spirometry promotes deep breathing and prevents pulmonary complications like pneumonia by encouraging alveolar expansion. The child’s repeated refusal to use the spirometer reduces pulmonary hygiene, especially postoperatively, when the risk of respiratory complications is already elevated.

Rationale for Incorrect Choices:

• Peritonitis: While the child has abdominal tenderness and absent bowel sounds, there’s no fever, guarding, or signs of systemic infection that would point clearly to peritonitis. The dressing is dry and intact, and the pain increase is gradual rather than sudden or severe, which makes pneumonia a more consistent risk here.
• Wound infection: A wound infection would typically present with signs like redness, swelling, warmth at the site, drainage, or an elevated temperature. In this case, the child’s dressing remains dry and intact, and their temperature is below the threshold for concern, making this less likely than pneumonia.
• Bowel sounds: Absent bowel sounds are expected in the early postoperative period following abdominal surgery and are not specifically indicative of pneumonia. While this may reflect slowed gastrointestinal motility, it is not the key sign pointing to a respiratory complication.
• Temperature: Although the child’s temperature has slightly increased, it remains within normal limits and is not a strong standalone indicator of infection. Without reaching the fever threshold prescribed for antipyretic administration, it does not strongly support pneumonia or other infection at this time.
• Surgical dressing: The dry and intact surgical dressing indicates proper wound healing without signs of infection or complications. It does not support a respiratory diagnosis and is not consistent with pneumonia risk.
• Abdominal tenderness: While present and worsening, it's a symptom of the surgical recovery and pain, leading to the shallow breathing, but it's not the cause of the risk for pneumonia directly, rather the shallow breathing due to the tenderness is.

Rationale for Correct Options:

• Preeclampsia is a hypertensive disorder of pregnancy that typically occurs after 20 weeks of gestation. This client has elevated blood pressure (156/96 mm Hg), proteinuria (25 mg/dL), hyperreflexia, headache, right upper quadrant pain, and facial edema—all hallmark signs of preeclampsia.
• Urinalysis shows elevated protein, which is a diagnostic criterion for preeclampsia. Proteinuria is a result of kidney involvement due to endothelial damage from hypertension indicating kidney involvement due to the systemic vascular changes in preeclampsia.

Rationale for Incorrect Options:

• Chorioamnionitis typically presents with maternal fever, uterine tenderness, foul-smelling amniotic fluid, and fetal tachycardia. This client is afebrile and has no signs of intrauterine infection.
• Preterm labor is indicated by cervical changes and regular uterine contractions, neither of which are present. The fetal monitor shows no contractions, and there are no reports of vaginal drainage or pressure.
• Serum WBC count is mildly elevated at 12,500/mm³, which can be normal in pregnancy and does not indicate infection or inflammation in this context.
• Fundal assessment: The fundal height of 29 cm at 30 weeks is within the normal range (+/- 2 cm), so it does not evidence a particular risk.