A nurse is caring for a 28-year-old female client who is 2 days postpartum in the postpartum unit following a cesarean birth. For each finding below, click to specify if the finding is consistent with the disease process of lactational mastitis, postpartum endometritis, or postpartum hemorrhage. Each finding may support more than one disease process.

Exhibits

For each finding below, click to specify if the finding is consistent with the disease process of lactational mastitis, postpartum endometritis, or postpartum hemorrhage. Each finding may support more than one disease process.

Choice A rationale: Weight loss

Weight loss during pregnancy, especially in the second trimester, is unexpected unless there is a medical condition such as hyperemesis gravidarum or other nutritional deficiencies. While mild weight fluctuations can occur, a consistent loss of weight rather than gradual gain suggests inadequate caloric intake due to persistent vomiting and dehydration.

Choice B rationale: Breast tenderness

Breast tenderness is a common and expected physiological change during pregnancy due to hormonal fluctuations, particularly increased estrogen and progesterone levels. It is not considered abnormal or unexpected at this stage of pregnancy.

Choice C rationale: Heart rate

A heart rate of 116/min is unexpected, as it is above the normal range for adults (typically 60–100/min). Pregnancy can cause a mild increase in heart rate, but tachycardia above 110/min may indicate dehydration, anemia, or electrolyte imbalance, all of which can stem from excessive vomiting and fluid loss.

Choice D rationale: Vomiting

While occasional nausea and vomiting (morning sickness) can be expected in early pregnancy, persistent vomiting up to eight times daily and symptoms of dehydration (dry mucosa, poor skin turgor, positive ketones in urine) raise concern for hyperemesis gravidarum, a more severe form of pregnancy-related nausea and vomiting.

Choice E rationale: Nasal congestion

Nasal congestion is common during pregnancy due to increased blood volume and vascular changes affecting the nasal mucosa. It is not unexpected and does not indicate a complication.

Choice F rationale: Respiratory rate

A respiratory rate of 20/min falls within the normal range for adults (typically 12–20/min), making it an expected finding.

Choice A rationale

A pounding headache, visual changes, and epigastric pain in a patient with pregnancy-induced hypertension (PIH), now known as gestational hypertension or preeclampsia, are serious signs indicating worsening disease severity. These symptoms suggest central nervous system irritability (headache, visual changes) and potential liver involvement or severe preeclampsia (epigastric pain), increasing the risk of eclampsia, which is characterized by seizures.

Choice B rationale

Magnesium sulfate is a medication commonly used to prevent seizures in patients with severe preeclampsia. While it can cause side effects such as flushing, warmth, and muscle weakness, it does not typically cause a pounding headache, visual changes, or epigastric pain. These symptoms are indicative of the underlying disease process, not the medication.

Choice C rationale

While hospitalization can induce anxiety in some patients, the specific combination of a pounding headache, visual changes, and epigastric pain in the context of pregnancy-induced hypertension strongly suggests a physiological basis related to the worsening of the hypertensive disorder, rather than solely psychological distress.

Choice D rationale

While epigastric pain can be associated with gastrointestinal issues, in a patient with pregnancy-induced hypertension experiencing a pounding headache and visual changes concurrently, it is more likely related to hepatic involvement or severe preeclampsia. A focused assessment of the gastrointestinal system alone would not adequately address the potential severity of the situation.