A nurse is caring for the client. Exhibits 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 signs of infection noted. No bowel movement since birth, hypoactive bowel sounds 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 Diagnostic Results Postpartum Day 3, 0900: Hemoglobin 11.1 g/dL WBC count 33,000/mm3
Explanation & Rationale
Rationale for Correct Answers: Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia. Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis). Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection. WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection. Rationale for Incorrect Answers: Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern. Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise. SaO₂ 97% on room air: This is normal oxygen saturation, not concerning