A nurse in an emergency department is planning care for a client who has abdominal trauma from a motor-vehicle crash. Which of the following provider prescriptions should the nurse implement first?

A. Frequent nosebleeds: While epistaxis can occur in some conditions affecting coagulation or blood pressure, it is not a characteristic finding in infants with coarctation of the aorta.

B. Increased intracranial pressure: Increased intracranial pressure is not a typical manifestation of coarctation of the aorta in infants. Neurologic symptoms are uncommon unless severe hypertension develops over time.

C. Upper extremity hypotension: Coarctation of the aorta usually results in hypertension in the upper extremities due to the obstruction distal to the aortic arch, not hypotension.

D. Weak femoral pulses: Weak or absent femoral pulses are an expected finding in coarctation of the aorta. The narrowing of the aorta obstructs blood flow to the lower extremities, leading to diminished pulses and lower blood pressure in the legs compared with the arms.

Rationale for correct choices

• Endometritis: The client presents with multiple risk factors for postpartum uterine infection, including cesarean delivery, prolonged rupture of membranes, and high parity. Clinical findings of uterine tenderness, foul-smelling lochia, fever, and tachycardia are classic for endometritis. The markedly elevated WBC count further supports an infectious process rather than normal postpartum changes.

• Uterus and lochia assessment: The uterus is tender to palpation and positioned above the umbilicus, with lochia that is dark brown and foul-smelling, which is abnormal in the postpartum period. Foul-smelling lochia is a hallmark sign of uterine infection due to bacterial overgrowth. Uterine tenderness reflects inflammation of the endometrial lining.

Rationale for incorrect choices

• Mastitis: Although the client reports breast firmness, warmth, and nipple discomfort, these findings are consistent with normal breast engorgement rather than infection. Mastitis typically presents with localized breast redness, unilateral pain, and systemic symptoms such as chills. The uterine findings and foul-smelling lochia are not associated with mastitis.

• Postpartum hemorrhage: Postpartum hemorrhage is characterized by excessive bleeding, hypotension, and signs of hypovolemia, which are not present in this client. The lochia amount is moderate rather than heavy and the hemoglobin level is stable. Although the fundus was initially boggy, it firmed with massage, indicating uterine tone is responsive.

• WBC: Leukocytosis can occur normally in the postpartum period due to physiologic stress and inflammation. While the WBC count is significantly elevated, it is not specific on its own for diagnosing endometritis. Without supporting uterine and lochia findings, an elevated WBC is not the strongest single piece of evidence for this diagnosis.

• Fever: A mild fever can occur postpartum due to breast engorgement, dehydration, or normal inflammatory responses. Fever alone does not localize the source of pathology or confirm uterine infection. When paired with uterine tenderness and foul-smelling lochia, the diagnosis becomes clearer. On its own, fever is insufficient to make the diagnosis.