A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

Rationale:

A. Assist the client to ambulate: Ambulation is encouraged after a laparoscopic cholecystectomy to stimulate peristalsis and help relieve abdominal distention caused by retained gas from insufflation during the procedure. It promotes bowel movement and absorption of gas, improving comfort.

B. Prepare the client for a paracentesis: Paracentesis is used to remove fluid from the peritoneal cavity, typically in clients with ascites or severe fluid retention. Abdominal distention after this procedure is usually due to gas, not fluid.

C. Insert a rectal suppository: Suppositories may stimulate bowel movements but are not the first-line intervention for post-laparoscopic gas-related distention. Encouraging natural movement through ambulation is more effective and less invasive initially.

D. Place the client in the prone position: The prone position is not typically used for relieving abdominal distention. It may cause discomfort and does not aid in gas movement through the intestines as effectively as upright or walking positions.

Rationale for Correct Choices

• Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
• Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.

Rationale for Incorrect Choices

• Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
• Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
• Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.