A home health nurse is caring for an older adult client who reports. "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take?

Rationale for correct choices

• Temperature 38.2° C (100.8° F). An elevated temperature in a postpartum client may indicate infection, especially in the context of prolonged rupture of membranes and cesarean delivery. Prompt follow-up is required to identify the source and initiate treatment to prevent progression to sepsis.

• WBC count 33,000/mm³. A markedly elevated WBC suggests an active inflammatory or infectious process. In postpartum clients, leukocytosis can signal endometritis, mastitis, or surgical site infection, necessitating immediate assessment and intervention.

• Client reports feeling unwell. A general feeling of being ill or "not right" in a postpartum client with fever is a significant subjective finding often preceding more objective signs of infection/sepsis.

• Uterus firm at 1 cm above the umbillous and tender to palpation. Uterine tenderness combined with fever and foul-smelling lochia is a cardinal sign of endometritis (infection of the uterine lining), the most common postpartum infection, especially after Cesarean section.

• Moderate amount of dark brown, foul-smelling lochia. Foul-smelling lochia is a hallmark of uterine infection such as endometritis. Combined with fever and leukocytosis, this finding warrants urgent evaluation, monitoring, and possible initiation of antibiotics.

• Breasts firm, heavy, and warm with nipple discomfort. These signs are consistent with mastitis, particularly in a breastfeeding client. Early recognition and treatment with supportive measures or antibiotics prevent worsening infection and systemic involvement.

• Fundus boggy but firmed with massage. A boggy fundus indicates uterine atony, which can lead to postpartum hemorrhage. Immediate attention is required to prevent excessive blood loss and maintain hemodynamic stability.

Rationale for incorrect choices

• Vital signs: Heart rate while slightly elevated can be physiologic due to postpartum recovery, mild fever, or pain. Respiratory rate is within normal limits for adults; does not indicate acute compromise. Blood pressure is within normal postpartum range and does not signal hemodynamic instability at this time. Oxygen saturation is normal, indicating adequate oxygenation.

• Surgical incision well approximated with slight edema, no redness or drainage: Mild edema at the incision site is expected and not indicative of infection at this time. Regular monitoring is appropriate.

• No bowel movement since birth, hypoactive bowel sounds: Delayed bowel movements and hypoactive sounds are common postpartum, especially after cesarean section. Monitoring and supportive care are sufficient unless other symptoms develop.

Rationale:

A. Decide which clients should be transported for a higher level of care: Determining transport priorities is usually the responsibility of the incident command or emergency response team, not individual unit nurses. Unit nurses provide patient assessments and recommendations but do not independently make these critical decisions.

B. Act as a spokesperson to provide information to the media: Communication with the media is handled by designated hospital public relations or administration personnel to ensure consistent and accurate information. Unit nurses are not responsible for media interactions during a disaster.

C. Recommend to the provider a list of clients for early discharge: Unit nurses are familiar with clients’ conditions, stability, and care needs, making them well-suited to recommend which clients can be safely discharged early. This helps prioritize resources and bed availability during a disaster while maintaining patient safety.

D. Determine the need for additional providers: Assessing staffing needs is the responsibility of the nurse manager or disaster coordinator. Unit nurses provide information about patient care demands but do not make staffing deployment decisions during an emergency.