The nurse has reviewed the Nurses' Notes from 5 days ago.

The nurse is providing discharge teaching to the client. Select the 3 statements the nurse should make.

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.

A. Report the incident to the nurse manager: Reporting to the nurse manager is important for institutional accountability and guidance, but it is not the immediate priority. The client’s safety must be addressed first.

B. Measure the client's vital signs: Assessing the client’s current condition, including vital signs, is the first action because it identifies any immediate physiologic effects of the medication error. This assessment guides subsequent interventions and determines the urgency of notifying the provider.

C. Fill out an incident report: Completing an incident report is required for documentation and quality improvement, but it is secondary to ensuring the client’s safety and assessing for adverse effects.

D. Notify the provider: The provider must be informed to determine medical interventions, but this step follows the initial assessment of the client to establish their current status and identify any immediate threats to safety.