A 14-year-old girl is concerned about her changing body.
Which nursing intervention is most appropriate?

Choice A rationale

Performing a fasciotomy is a surgical procedure, not an initial nursing intervention. While it may be necessary to relieve compartment syndrome, it is outside the scope of nursing practice and is typically performed by a physician. The nurse's role is to identify the signs and symptoms and escalate to the medical team for this definitive treatment.

Choice B rationale

Loosening the cast dressings or bandages directly addresses the potential cause of compartment syndrome by reducing external compression. This action aims to improve blood flow and nerve function by alleviating pressure on the neurovascular structures within the confined space. This can prevent further tissue ischemia and damage.

Choice C rationale

Elevating the affected limb above heart level can paradoxically worsen compartment syndrome. Elevation decreases arterial perfusion pressure, further compromising blood flow to the already ischemic tissues within the rigid fascial compartment. This can exacerbate tissue hypoxia and cellular damage, increasing the risk of irreversible injury.

Choice D rationale

Applying ice to the affected area causes vasoconstriction, which would further reduce blood flow to the compromised tissues within the compartment. This decrease in perfusion would exacerbate ischemia and hypoxia, potentially worsening tissue damage and accelerating the progression of compartment syndrome. Therefore, ice application is contraindicated.

Choice A rationale

Lochia rubra, characterized by bright red discharge, typically lasts for the first 3-5 days postpartum. Its presence at 5 weeks postpartum would be abnormal and could indicate a complication such as retained placental fragments or infection, necessitating further medical evaluation due to prolonged uterine bleeding.

Choice B rationale

Lochia serosa, a pinkish-brown discharge, typically follows lochia rubra and can persist for about 2 to 3 weeks postpartum. While some individual variation exists, its presence up to 6 weeks postpartum as the predominant discharge type is less common and might suggest a slower than average uterine involution.

Choice C rationale

Complete cessation of lochia by 5 weeks postpartum is not typical for most individuals. The puerperium, or postpartum period, involves significant uterine involution and discharge. While the volume decreases, some form of lochia, usually alba, is still physiologically expected as the uterus continues to heal and shed decidual tissue.

Choice D rationale

Lochia alba, a yellowish-white discharge, is the final stage of lochia and typically begins around 2 to 6 weeks postpartum, continuing for up to 6 weeks or even longer in some individuals. This discharge consists of leukocytes, decidual cells, mucus, and bacteria, signifying the continued, normal healing and involution of the uterus.