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:

• Antibiotic prescription: The client presents with signs of a postoperative wound infection: fever (38.8°C), increased WBC count (14,800/mm³), purulent drainage, and incisional swelling. These findings warrant prompt antibiotic therapy to prevent further complications.
• WBC count: The rise in WBC count from 8,000 to 14,800/mm³ over three days is a key indicator of an infectious process, particularly concerning postoperatively. It supports the need for antibiotics.
• Temperature: The client’s fever (38.8°C/101.8°F) is consistent with a systemic response to infection. In combination with the elevated WBC and wound findings, it confirms the need for antimicrobial treatment.

Rationale for Incorrect Choices:

• IV fluids: While fluids are essential postoperatively, the client shows no signs of hypovolemia or dehydration—mucous membranes are moist and blood pressure is stable. Fluids are not the priority.
• Laxative: Although the client hasn’t had a bowel movement, they are passing flatus and show some motility. The acute concern is infection, not constipation, making laxatives inappropriate as the primary intervention.
• Prescription for IV iron: The client has stable but low hemoglobin levels (around 10.3 g/dL), likely due to surgery. However, there’s no acute drop or symptomatic anemia requiring immediate IV iron over addressing infection.
• Hemoglobin: Although low, the hemoglobin level is stable and does not indicate an acute issue. It does not justify antibiotic use or serve as the primary clinical concern at this time.
• Bowel sounds: Hypoactive bowel sounds are common postoperatively and are not indicative of infection alone. They do not support the use of antibiotics directly.
• Blood pressure: The client’s blood pressure remains within normal limits postoperatively and does not show signs of septic or hypovolemic shock. It’s not relevant to initiating antibiotics.
• Transferrin level: Transferrin reflects protein status and iron transport; although low, it doesn’t indicate acute infection. It is unrelated to the decision to initiate antibiotics.
• Skin turgor: Normal skin turgor suggests adequate hydration. There’s no indication of dehydration or fluid imbalance requiring action.
• Bowel movements: Absence of bowel movement is common postoperatively and expected after colon surgery. While important to monitor for ileus, these are not the primary indicators for an antibiotic prescription.

A. Apply internal fetal monitor: Internal monitoring requires ruptured membranes and cervical dilation, which are not present. External monitoring is adequate at this stage of gestation and clinical condition.
B. Encourage bed rest: Bed rest helps reduce maternal blood pressure and cerebral stimulation, which lowers the risk of seizure activity. It also promotes uteroplacental perfusion, supporting fetal oxygenation and growth.
C. Assess DTR: Hyperreflexia is a common neurologic sign of severe preeclampsia and can indicate impending seizures. Regular DTR assessment also helps evaluate the therapeutic effect of magnesium sulfate if administered.
D. Decrease lighting in the client's room: Dimming the lights minimizes sensory stimulation that can provoke seizures in clients with preeclampsia. It also contributes to a calming environment that supports neurologic stability.
E. Prepare for amniocentesis: Amniocentesis is not currently indicated because there's no concern for fetal lung maturity, genetic testing, or intraamniotic infection. Clinical focus is on maternal stabilization.
F. Initiate contact precautions: There are no clinical signs or lab findings indicating an infectious process that requires isolation. Standard precautions remain appropriate for this non-infectious condition.
G. Check urinary output: Oliguria may signal renal impairment, which is a complication of severe preeclampsia. Monitoring urine output also helps determine fluid status and the need for intervention or delivery.
H. Monitor blood pressure: Continuous or frequent BP monitoring helps detect progression to severe preeclampsia or eclampsia. It guides timely decisions about antihypertensive use or early delivery planning.