A nurse is assisting with the care of a female client who is at 28 weeks of gestation in the maternity unit.

Exhibits

Complete the diagram by dragging 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.

Choice A rationale

This statement is incorrect because after a cesarean birth, clients are usually started on clear liquids and then gradually progress to regular food as tolerated. Swallowing safety is related to anesthesia recovery, not cesarean birth recovery.

Choice B rationale

This statement is incorrect because the client does not need to stay flat on their back for 24 hours. Early ambulation is encouraged to prevent complications such as deep vein thrombosis and promote recovery.

Choice C rationale

This statement is incorrect because the urinary catheter is typically removed within 24 hours after surgery to reduce the risk of urinary tract infections and encourage normal bladder function.

Choice D rationale

This statement is correct because after a cesarean birth, the nurse will frequently assess the uterus for firmness and massage it as needed to prevent postpartum hemorrhage.

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.