A woman had a cesarean birth after a prolonged trial of labor. When assessing the patient, the nurse notes the patient is lethargic, has a pulse of 130 beats/minute, and states: "I'm glad I have so little lochia; I'm too tired to change my pad."
What action by the nurse is most appropriate?
A.
Assess the amount of lochia on the peri-pad.
B.
Cluster the nursing care given to allow uninterrupted sleep.
C.
Have the woman get up and attempt to void.
D.
Take a full set of vital signs and call the provider.
ANS: D
Signs of puerperal infection include tachycardia, malaise, uterine tenderness, and subinvolution. Lochia can be heavy and foul smelling or scant and odorless, depending on the offending organism. The nurse should take a full set of vital signs, perform a complete assessment, and notify the health-care provider.
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