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A nurse on a postpartum unit is caring for a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Vital Signs:

Postpartum day 3, 0815:

Temperature 38.2° C (100.8° F)

Heart rate 104/min

Respiratory rate 18/min

BP 108/70 mm Hg

SaO2 97% on room air

Nurses' Notes:

Postpartum day 3, 0815:

Client reports feeling unwell.

Lung sounds clear but diminished in the bases.

Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding.

Uterus firm at 1 cm above the umbilicus and tender to palpation.

Fundus boggy but firmed with massage.

Moderate amount of dark brown, foul-smelling lochia noted.

Surgical incision well approximated with slight edema present; no redness or drainage noted.

No bowel movement since birth, hypoactive bowel sounds.

Diagnostic Results:

Postpartum day 3, 0900:

Hemoglobin 11.1 g/dL (greater than 11 g/dL)

WBC count 33,000/mm3 (5,000 to 10,000/mm)

Temperature 38.2° C (100.8° F)

Heart rate 104/min

BP 108/70 mm Hg

SaO2 97% on room air

Client reports feeling unwell

Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding

Uterus firm at 1 cm above the umbilicus and tender to palpation

Moderate amount of dark brown, foul-smelling lochia noted

Surgical incision well approximated with slight edema present; no redness or drainage noted

WBC count 33,000/mm3 (5,000 to 10,000/mm)

Answer and Explanation

The Correct Answer is ["A","B","E","G","H","J"]

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.

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Free Nursing Study Resources

Correct Answer is ["D","E"]

Explanation

A. Disseminated intravascular coagulation: DIC is a rare, life-threatening condition associated with severe complications such as placental abruption or amniotic fluid embolism. The client currently has no signs or risk factors indicating DIC.

B. Preeclampsia: Preeclampsia is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. This client’s blood pressure is within normal limits, so preeclampsia is not an immediate concern at this time.

C. Placenta previa: Placenta previa involves implantation of the placenta over the cervical os, which would present with painless bright-red vaginal bleeding. The client’s lower back pain and pinkish discharge, along with contractions, do not suggest placenta previa.

D. Sepsis: The client has a fever (38.4° C / 101.1° F) and reports vaginal discharge, which could indicate an intrauterine or urinary tract infection. Infections during pregnancy can rapidly progress to sepsis, so the client is at increased risk and requires close monitoring.

E. Preterm prelabor rupture of membranes (PPROM): The client is experiencing uterine contractions at 33 weeks of gestation with pinkish vaginal discharge. These findings, along with her history of preterm birth, place her at risk for PPROM and preterm labor.

F. Seizures: Seizures are primarily associated with eclampsia or epilepsy. The client has no history of seizure disorder or signs of preeclampsia, making this complication unlikely at this time.

A. Avoid eye contact with the client. B. Encourage the client to lie down in a quiet room. C. Ask the client directly what they are hearing. D. Refer to the hallucinations as if they are real.

Correct Answer is C

Explanation

A. Avoid eye contact with the client: Avoiding eye contact can convey disinterest or disengagement, which may increase the client’s sense of isolation. Therapeutic engagement requires maintaining appropriate eye contact to promote trust and effective communication.

B. Encourage the client to lie down in a quiet room: Isolating the client in a quiet room may intensify auditory hallucinations, as there are fewer environmental stimuli to help the client reality-test. Structured interaction and distraction techniques are generally more effective.

C. Ask the client directly what they are hearing: Engaging the client in a nonjudgmental discussion about their hallucinations helps the nurse understand the content, assess risk, and provide support. This approach promotes reality orientation, therapeutic rapport, and early identification of command hallucinations that may pose safety risks.

D. Refer to the hallucinations as if they are real: Validating hallucinations as real can reinforce psychotic thinking and perpetuate the hallucinations. The nurse should acknowledge the client’s experience without confirming the reality of the voices.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been admitted to the antepartum unit. Which of the following complications is the client at risk of developing? Select the 2 complications the client is at risk of developing.

Correct Answer is ["D","E"]

Explanation

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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