A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Rationale for correct choices:

• Temperature 38.2° C (100.8° F): An elevated temperature in the postpartum period may indicate infection, particularly given the prolonged rupture of membranes and cesarean birth. Early recognition is essential to prevent progression to sepsis.
• Heart rate 104/min: Tachycardia can be an early sign of infection or postpartum hemorrhage. In combination with fever and elevated WBC, this warrants prompt evaluation.
• Client reports feeling unwell: The client’s report of illness is the first indicator of an ongoing disease process which warrants further evaluation, coupled by other findings, this indicates that there is something wrong.
• WBC count 33,000/mm³: This is markedly elevated beyond the normal postpartum range and indicates a possible systemic infection. This finding requires immediate intervention and notification of the provider.
• Fundus boggy but firmed with massage: A boggy uterus suggests uterine atony, which increases the risk of postpartum hemorrhage. Continuous monitoring is needed to prevent excessive blood loss.
• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a sign of endometritis or uterine infection. Early identification and treatment reduce the risk of sepsis and further complications.

Rationale for incorrect choices:

• Vital Signs Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97% on room air: This is within normal limits and does not indicate respiratory compromise at this time. Blood pressure is within normal postpartum range; no immediate intervention is needed. Oxygen saturation is adequate and does not require urgent follow-up.
• Breast firmness with moderate nipple discomfort: These findings are consistent with normal lactation and engorgement, and do not indicate an immediate complication.
• Surgical incision well-approximated with slight edema: Mild edema without redness or drainage is expected postoperatively and does not require immediate intervention.
• No bowel movement since birth, hypoactive bowel sounds: While monitoring is necessary for constipation, this is a common postpartum finding, especially after surgery and opioid use, and does not require urgent intervention.

A. "You will be given access to the medical records of every client in the facility.": Access to electronic medical records is restricted based on the nurse’s role and need-to-know basis to protect client confidentiality. Nurses only view records of clients under their care.

B. "You will be asked to change your password once per year.": Most facilities require more frequent password changes, often every 60–90 days, to maintain system security. Annual changes alone are insufficient for protecting client data.

C. "Information Technology will install a firewall to secure client information.": Firewalls and other cybersecurity measures help protect electronic health information from unauthorized access. Including this ensures nurses understand that the system has built-in technical safeguards for privacy and security.

D. "Documentation of sensitive material is performed by the charge nurse.": All licensed nurses are responsible for accurate, complete, and timely documentation of client care, including sensitive material. Responsibility is not limited to the charge nurse.