A nurse on a postpartum unit is caring for a client. Exhibits 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/mm3)

Rationale for correct choices: Temperature 38.2° C (100.8° F): An elevated temperature in the postpartum period may indicate infection, particularly given the prolonged rupture of membranes and cesarean birth. Early recognition is essential to prevent progression to sepsis. Heart rate 104/min: Tachycardia can be an early sign of infection or postpartum hemorrhage. In combination with fever and elevated WBC, this warrants prompt evaluation. Client reports feeling unwell: The client’s report of illness is the first indicator of an ongoing disease process which warrants further evaluation, coupled by other findings, this indicates that there is something wrong. WBC count 33,000/mm³: This is markedly elevated beyond the normal postpartum range and indicates a possible systemic infection. This finding requires immediate intervention and notification of the provider. Fundus boggy but firmed with massage: A boggy uterus suggests uterine atony, which increases the risk of postpartum hemorrhage. Continuous monitoring is needed to prevent excessive blood loss. Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a sign of endometritis or uterine infection. Early identification and treatment reduce the risk of sepsis and further complications. Rationale for incorrect choices: Vital Signs Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97% on room air: This is within normal limits and does not indicate respiratory compromise at this time. Blood pressure is within normal postpartum range; no immediate intervention is needed. Oxygen saturation is adequate and does not require urgent follow-up. Breast firmness with moderate nipple discomfort: These findings are consistent with normal lactation and engorgement, and do not indicate an immediate complication. Surgical incision well-approximated with slight edema: Mild edema without redness or drainage is expected postoperatively and does not require immediate intervention. No bowel movement since birth, hypoactive bowel sounds: While monitoring is necessary for constipation, this is a common postpartum finding, especially after surgery and opioid use, and does not require urgent intervention.