A nurse is caring for a client.

Click to highlight the findings that are contraindications to the use of a combined oral contraceptive. To deselect a finding, click on the finding again.

History and Physical

1 year ago:

33-year-old client here for routine physical examination and is requesting contraception until they attempt to conceive in about a year. Client has diabetes mellitus, diagnosed 24 years ago. Care is managed by an endocrinologist, has an insulin pump. States HbA1c was 6.7% last month. Client also has migraine headaches with aura and gastroesophageal reflux disease.

Client is a lifetime nonsmoker, reports rarely drinking alcohol. Client is a law enforcement officer and works full time. Reports exercising three or four times per week, usually walking for 2 to 3 miles or riding a stationary bike. Client had a tonsillectomy at 6 years of age. Also had a deep vein thrombosis while travelling internationally 5 years ago.

A. Ritualistic behavior: Ritualistic or repetitive behaviors are characteristic of obsessive-compulsive or obsessive-compulsive personality disorder, not narcissistic personality disorder. These behaviors reflect a need for control rather than grandiosity or self-centeredness.

B. Preoccupied with aging: Clients with narcissistic personality disorder often exhibit preoccupation with self-image, physical appearance, and how aging affects their attractiveness or status. Concerns about aging align with the disorder’s core features of vanity and self-importance.

C. Exhibits separation anxiety: Separation anxiety is typically observed in anxiety disorders, particularly in children, and is not a hallmark feature of narcissistic personality disorder, which centers on self-esteem regulation and interpersonal manipulation.

D. Suspicious of others: Suspiciousness is more characteristic of paranoid personality disorder. While narcissistic clients may be sensitive to criticism, pervasive distrust of others is not a defining trait of narcissistic personality disorder.

Rationale for correct choices

• Temperature 38.2° C (100.8° F): A temperature above 38° C after the first 24 hours postpartum is concerning for infection. This client has multiple risk factors including cesarean delivery and prolonged rupture of membranes. Fever in this patient warrants immediate evaluation for postpartum endometritis or mastitis.

• Heart rate 104/min: Tachycardia can indicate a systemic inflammatory or infectious process in the postpartum period. When paired with fever and uterine tenderness, it raises concern for sepsis or worsening uterine infection. Early recognition is critical to prevent complications.

• Client reports feeling unwell: A subjective report of feeling unwell is an important early sign of infection or systemic illness. This symptom, combined with abnormal vital signs and laboratory findings, suggests the client may be developing a postpartum complication requiring prompt intervention.

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness beyond the immediate postpartum period is abnormal and commonly associated with endometritis. The elevated fundal height also suggests delayed uterine involution, reinforcing concern for uterine infection.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a classic indicator of postpartum uterine infection. Normal lochia should not have an offensive odor, and this finding strongly supports suspected endometritis requiring immediate follow-up.

• WBC count 33,000/mm³: Although mild leukocytosis is expected postpartum, a WBC count this elevated exceeds normal physiologic changes. In the presence of fever and uterine findings, this level is highly suggestive of an acute infectious process.

Rationale for incorrect choices

• Breasts feel firm, heavy, and warm with moderate nipple discomfort: These findings are consistent with normal breast engorgement during early breastfeeding. While uncomfortable, they are expected postpartum changes and do not indicate infection in the absence of localized redness or systemic signs.

• Surgical incision well approximated with slight edema present: Mild edema without redness, drainage, or separation is a normal postoperative finding. There are no signs suggesting a surgical site infection at this time.

• Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97%: These vital signs fall within expected postpartum ranges and do not indicate acute instability. They do not contribute to the immediate concern for infection or deterioration.