A nurse is assisting with the care of a 28-year-old female client who gave birth 3 days ago in the maternal newborn unit.

Exhibits

Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Endometritis is indicated by a high temperature (38.4°C), elevated heart rate (108/min), foul-smelling lochia, and a tender boggy uterus. These are classic signs of infection post-cesarean birth, particularly following prolonged rupture of membranes, which increases infection risk. Administering broad-spectrum antibiotics targets the infection, while oxytocic medication helps manage uterine atony and promote uterine contraction to expel infected lochia.

Actions Explanation:

1. Administer broad-spectrum antibiotic medication: This addresses the underlying infection causing endometritis.
2. Monitor the administration of an oxytocic medication: Ensures uterine contraction, reducing uterine atony and helping clear infected materials.

Parameters to Monitor:

1. Temperature: Indicates the presence and resolution of infection.
2. Lochia amount and odor: Helps assess the severity of infection and effectiveness of treatment.

Other Conditions:

• B. Urinary tract infection (UTI): Less likely since the client denies urinary symptoms like burning or difficulty.
• C. Deep vein thrombosis (DVT): Bilateral lower extremity edema without pain, warmth, or tenderness doesn't align with unilateral swelling/pain typical of DVT.
• D. Engorgement: Not likely since the client is bottle-feeding and denies nipple discomfort; also, the lochia characteristics and boggy uterus point to infection.