A nurse is caring for a client who is 2 hours postpartum.
The client has an IV infusion of lactated Ringer’s with 25 units of oxytocin and large lochia rubra.
Vital signs include blood pressure 146/81, pulse 80/min, and respirations 18/min.
Which of the following actions should the nurse clarify with the provider?

Choice A rationale:

During the taking-in phase, which typically lasts 2-3 days postpartum, the client's primary focus is on herself and her own

needs. She may be physically exhausted and emotionally overwhelmed by the birthing experience.

Interest in learning about newborn care is more characteristic of the taking-hold phase, which begins around the third day

postpartum.

Choice B rationale:

Concerns about managing at home are more likely to arise during the letting-go phase, which begins around the fourth week

postpartum.

During this phase, the mother is adjusting to her new role and responsibilities, and she may feel anxious about her ability to

care for her baby on her own.

Choice C rationale:

While some mothers may be eager to share their birth stories during the taking-in phase, it is not a universal characteristic of

this phase.

Many mothers are still processing their experiences and may not be ready to talk about them in detail.

Choice D rationale:

The focus on personal needs and recovery is a hallmark of the taking-in phase.

The mother is typically preoccupied with physical comfort, rest, and nourishment.

She may also be emotionally labile, experiencing a range of emotions from euphoria to sadness.

Choice A rationale:

Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's

thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This

triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to

fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.

Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result

from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or

severe, and they often precede a rise in temperature.

Choice B rationale:

Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be

present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign

of endometritis, it's not considered a primary manifestation.

Choice C rationale:

Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of

endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,

constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.

Choice D rationale:

Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual

vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all

women with endometritis will have abnormal discharge.