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 Findings: • Temperature 38.2° C (100.8° F): Fever in a postpartum client may indicate infection such as endometritis, mastitis, or wound infection. Early detection is essential to prevent progression to sepsis, especially after cesarean birth and prolonged rupture of membranes. • Heart rate 104/min: Tachycardia in the postpartum period may reflect infection, pain, or hypovolemia. Coupled with fever and leukocytosis, it indicates systemic inflammatory response requiring urgent evaluation. • Client reports feeling unwell: Subjective complaints of malaise can be an early indicator of infection or postpartum complications. When combined with objective findings like fever and elevated WBC, it requires prompt follow-up. • WBC count 33,000/mm³: Significantly elevated leukocytes indicate a severe inflammatory or infectious process. Immediate assessment and intervention are necessary to prevent progression to sepsis. • Uterus firm at 1 cm above the umbilicus and tender to palpation; fundus boggy but firmed with massage: A boggy fundus and uterine tenderness can indicate uterine atony or early postpartum infection. These findings, especially with elevated temperature and WBC, require urgent monitoring and intervention. • Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is abnormal and may signal endometritis, particularly after cesarean delivery and prolonged rupture of membranes. This requires prompt evaluation and potential initiation of antibiotics. Rationale for Incorrect Findings: • Breasts firm, heavy, and warm with moderate nipple discomfort while breastfeeding: These are expected findings related to milk engorgement. They are typical postpartum changes and can be managed with frequent breastfeeding or expressing milk. • Surgical incision well approximated with slight edema, no redness or drainage: Slight edema at the incision site is normal post-cesarean. Absence of redness, warmth, or drainage indicates no infection requiring urgent intervention. • BP 108/70 mm Hg: Blood pressure is within the acceptable range for a postpartum client and does not indicate immediate concern. • Respiratory rate 18/min: This is within normal limits for an adult and does not require urgent intervention. • SaO2 97% on room air: Oxygen saturation is within normal range and indicates adequate oxygenation, not requiring immediate follow-up. • Hemoglobin 11.1 g/dL: This value is within normal postpartum limits, indicating no acute anemia or need for immediate intervention.