A nurse is caring for a client who is at 33 weeks of gestation.

Medical History Gravida 2 Para 1 Preeclampsia
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.

B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.

C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.

D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.

Leukocytosis: Indication of Worsening Condition - Leukocytosis, an increase in white blood cell count, may indicate an exacerbation of the deep vein thrombosis or the development of an infection.

Redness in the extremity: Indication of Worsening Condition - Redness in the extremity suggests inflammation or worsening of the deep vein thrombosis.

Scant lochia rubra: Indication of Improving Condition - Scant lochia rubra indicates a decrease in postpartum bleeding, which is a positive sign.

Increased warmth in the extremity: Indication of Worsening Condition - Increased warmth in the extremity suggests increased inflammation and may indicate progression of the deep vein thrombosis.

Tachycardia: Indication of Worsening Condition - Tachycardia, an elevated heart rate, can be a sign of worsening condition, possibly due to complications such as pulmonary embolism.

Decreased extremity edema: Indication of Improving Condition - Decreased extremity edema suggests reduced swelling, which is a positive sign indicating improvement in circulation and reduction of fluid accumulation in the affected limb.