The nurse has reviewed the Vital Signs, Nurses' Notes, and Provider Notes from 1 week ago.

Select words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing

_____

and

_____

.

A. "I should ask the provider to write a prescription for mechanical restraints as needed.": Prescriptions for restraints must specify a time-limited duration and cannot be written as “as needed.” This ensures that the use of restraints is justified, monitored, and reevaluated according to legal and regulatory standards.

B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints.": Skin integrity should be assessed much more frequently—typically every 2 hours—to prevent pressure injuries, skin breakdown, and circulation issues associated with prolonged restraint use.

C. "I should expect the provider to evaluate the client within 4 hours of restraint application.": For adults, the provider must evaluate the client within 1 hour of initiating restraints. Waiting 4 hours would not meet safety or regulatory requirements for ongoing assessment.

D. "I should visually monitor the client continuously when in mechanical restraints.": Continuous visual monitoring is essential to ensure client safety, detect signs of distress, monitor for respiratory compromise, and prevent injury while the restraints are in place.

Rationale for correct choices

• Endometritis: The client presents with multiple risk factors for postpartum uterine infection, including cesarean delivery, prolonged rupture of membranes, and high parity. Clinical findings of uterine tenderness, foul-smelling lochia, fever, and tachycardia are classic for endometritis. The markedly elevated WBC count further supports an infectious process rather than normal postpartum changes.

• Uterus and lochia assessment: The uterus is tender to palpation and positioned above the umbilicus, with lochia that is dark brown and foul-smelling, which is abnormal in the postpartum period. Foul-smelling lochia is a hallmark sign of uterine infection due to bacterial overgrowth. Uterine tenderness reflects inflammation of the endometrial lining.

Rationale for incorrect choices

• Mastitis: Although the client reports breast firmness, warmth, and nipple discomfort, these findings are consistent with normal breast engorgement rather than infection. Mastitis typically presents with localized breast redness, unilateral pain, and systemic symptoms such as chills. The uterine findings and foul-smelling lochia are not associated with mastitis.

• Postpartum hemorrhage: Postpartum hemorrhage is characterized by excessive bleeding, hypotension, and signs of hypovolemia, which are not present in this client. The lochia amount is moderate rather than heavy and the hemoglobin level is stable. Although the fundus was initially boggy, it firmed with massage, indicating uterine tone is responsive.

• WBC: Leukocytosis can occur normally in the postpartum period due to physiologic stress and inflammation. While the WBC count is significantly elevated, it is not specific on its own for diagnosing endometritis. Without supporting uterine and lochia findings, an elevated WBC is not the strongest single piece of evidence for this diagnosis.

• Fever: A mild fever can occur postpartum due to breast engorgement, dehydration, or normal inflammatory responses. Fever alone does not localize the source of pathology or confirm uterine infection. When paired with uterine tenderness and foul-smelling lochia, the diagnosis becomes clearer. On its own, fever is insufficient to make the diagnosis.