The nurse is assessing a client who is 2 weeks postpartum.
The nurse would be concerned about mastitis if which of the following were noted? Select all that apply.

Choice A rationale

Increasing nasal discharge is a common symptom of upper respiratory tract infections and does not specifically indicate a progression to airway occlusion in croup. While it contributes to overall respiratory distress, it is not the most critical sign of a life-threatening compromise of the airway in this condition.

Choice B rationale

A harsher cough, often described as a "barking" cough, is a characteristic symptom of croup caused by inflammation of the larynx, trachea, and bronchi. While concerning, it is not the most reliable indicator of impending airway occlusion. The cough may be present throughout the illness without a complete occlusion.

Choice C rationale

An increasing respiratory rate is an early compensatory mechanism in response to airway obstruction and hypoxia. While it indicates respiratory distress, it is not the most significant sign of impending airway occlusion. It can occur with many respiratory issues and is often a precursor to more severe signs.

Choice D rationale

A toddler stating they are tired and wanting to sleep is a serious and late sign of hypoxia. This indicates that the child is becoming fatigued from the increased work of breathing, leading to decreased respiratory effort. This mental status change signals that the body's compensatory mechanisms are failing, and respiratory failure and airway occlusion are imminent.

Choice A rationale

Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. The primary concern is the potential for umbilical cord prolapse due to the gush of amniotic fluid, which can compromise fetal oxygenation. The fluid rate can be addressed after ensuring fetal well-being.

Choice B rationale

Providing a clean gown and linens is important for client comfort and hygiene but is not a priority over assessing fetal status. A change in linens can be done after the immediate safety of the fetus is confirmed, as a compromised fetal heart rate requires immediate intervention.

Choice C rationale

Assessing the fetal heart rate is the highest priority action after an amniotomy. The sudden release of amniotic fluid increases the risk of an umbilical cord prolapse, where the cord can be compressed, leading to a sudden decrease in fetal oxygenation and an emergent bradycardia. The normal fetal heart rate is 110-160 beats per minute.

Choice D rationale

Assisting the client with perineal hygiene is an important comfort measure and infection prevention strategy, but it is not the most critical and immediate action. The potential for a sudden, life-threatening change in fetal status due to cord prolapse takes precedence over hygiene.