A nurse on a postpartum unit is caring for a client. For each finding, click to specify if the finding is consistent with uterine atony or infection.

Exhibits

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. Place a warm pack on the incisional area: Applying a warm pack immediately postoperatively can increase blood flow and risk bleeding or swelling at the surgical site. Cold packs are generally preferred in the immediate postoperative period to reduce inflammation.

B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated after hernia repair unless the client has a comorbid condition like heart or renal failure. Adequate hydration supports healing and normal bowel and urinary function.

C. Elevate the client's scrotum on a pillow: Elevating the scrotum helps reduce swelling and discomfort after hernia repair, especially if the inguinal area is involved. This intervention promotes venous return and prevents complications like hematoma formation.

D. Encourage the client to sit to void: Sitting to void is not routinely necessary after hernia repair unless the client has mobility issues. There’s no specific benefit to this position in a typical male postoperative client.

Rationale:

A. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.

B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.

C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.

D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.