A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Rationale for Correct Choices:

• Endometritis: The client has systemic signs (feeling unwell, low-grade fever), elevated WBC count, and local uterine findings indicating infection. Endometritis is a common complication postpartum, especially after cesarean birth with membrane rupture exceeding 24 hours.
• Uterus and lochia assessment: The presence of a boggy, tender uterus and foul-smelling, dark brown lochia are classic signs of endometritis. These findings, in the setting of cesarean delivery and prolonged rupture of membranes, point to uterine infection as the primary concern.

Rationale for Incorrect Choices:

• Pneumonia: The client lacks hallmark signs of pneumonia, such as productive cough, abnormal sputum, or abnormal chest auscultation like crackles or wheezing. Normal respiratory rate and oxygenation further reduce the likelihood of a lower respiratory tract infection.
• Mastitis: Typically presents with unilateral breast pain, erythema, warmth, and systemic symptoms like high fever and malaise. The client’s symptoms are more consistent with engorgement, making mastitis an unlikely cause.
• Lung sounds: While lung sounds are diminished at the bases, they are otherwise clear, and the client has normal respiratory rate and oxygen saturation. These findings do not support a diagnosis of pneumonia and may simply reflect postoperative atelectasis or limited mobility.
• Breast and nipple changes: Breast fullness and nipple discomfort are expected during lactation and suggest engorgement rather than mastitis. There is no redness, localized heat, or severe pain reported.

A. Initiate fundal massage: Fundal massage is typically used postpartum to stimulate uterine contraction and prevent hemorrhage, not during active labor, so this is not appropriate at this stage.
B. Apply a fetal heart rate monitor: Monitoring the fetal heart rate is essential after membrane rupture to assess fetal well-being and detect signs of distress during labor, making this the priority action.
C. Insert an indwelling urinary catheter: While sometimes necessary during labor if the client cannot void, catheter insertion is not a routine first action and depends on the client’s condition and labor progress.
D. Initiate an oxytocin IV infusion: Oxytocin is used to induce or augment labor but should only be started based on the healthcare provider’s order and assessment of labor progression, not immediately after membrane rupture.