A nurse on a postpartum unit is caring for a client.

Exhibits

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. (Note: Each column must have at least 1 response option selected)

Rationale:

A. Sleep pattern: Two days without sleep is a red flag in bipolar disorder and may lead to worsening mania or psychosis. Addressing sleep deprivation is a priority to reduce the risk of exhaustion or psychotic deterioration.

B. Skin turgor: Poor skin turgor suggests dehydration, which may be due to poor fluid intake or prolonged activity. It requires immediate follow-up to prevent complications like electrolyte imbalances or renal injury.

C. Hallucinations: Persistent visual hallucinations may indicate an acute psychotic episode or manic psychosis. These require immediate psychiatric intervention to ensure client safety and stabilization.

D. Heart rate: A heart rate of 120/min indicates tachycardia, possibly related to dehydration, agitation, or underlying mania. It requires prompt evaluation to rule out cardiovascular strain or systemic causes.

E. Hygiene: While poor hygiene is a concern and can indicate mental health deterioration, it is not immediately life-threatening. It can be addressed after acute issues such as dehydration, tachycardia, and psychosis are managed.

Rationale:

A. Assess the client's peripheral pulses every 15 min: Frequent assessment of peripheral pulses is essential to monitor for signs of arterial obstruction, bleeding, or hematoma formation at the femoral site. This helps ensure adequate perfusion and detect complications early.

B. Elevate the head of the client's bed to 45°: After femoral catheterization, the head of the bed should be elevated no more than 30° to reduce pressure at the puncture site and prevent bleeding. A 45° angle may increase the risk of hemorrhage.

C. Change the client's dressing 4 hr following the procedure: The dressing should remain in place and be monitored for signs of bleeding or saturation. Routine dressing changes shortly after the procedure are not recommended unless soiled or ordered.

D. Instruct the client to flex the right knee every 30 min: Flexing the leg increases the risk of dislodging the clot or reopening the arterial puncture site. The affected leg should remain straight and immobilized for several hours post-procedure.