A nurse is caring for a female client following an emergency cesarean birth in the postpartum unit.

Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing

_________

and

________

.

Choice A rationale: Stopping breastfeeding is not indicated in postpartum infections unless the infection is a contraindication such as HIV or active tuberculosis. Breastfeeding promotes uterine contraction by releasing oxytocin, which helps reduce bleeding and promotes healing. Additionally, breast milk provides immunological benefits to the newborn. The client’s infection appears localized to the uterus (endometritis), and there is no evidence breastfeeding worsens maternal infection or neonatal risk here.

Choice B rationale: Initiating broad-spectrum antibiotics is scientifically appropriate for suspected postpartum endometritis, especially with fever >38°C, tachycardia, foul-smelling lochia, and abdominal tenderness. These antibiotics target polymicrobial infections commonly involving aerobic and anaerobic bacteria, preventing progression to sepsis. Timely antibiotic therapy reduces maternal morbidity and accelerates recovery. Normal temperature is 36.5–37.5°C; this client’s rising fever to 38.9°C indicates infection requiring treatment.

Choice C rationale: Airborne isolation precautions are unnecessary because common postpartum infections such as endometritis are not transmitted via airborne routes but rather by endogenous flora or direct contamination. Airborne pathogens include tuberculosis, varicella, and measles, none of which are suggested by this client’s presentation or history. Implementing unnecessary airborne precautions wastes resources and increases patient isolation without scientific benefit.

Choice D rationale: Strict bedrest is not routinely indicated in postpartum infections unless severe systemic illness is present. Early mobilization improves circulation, reduces risk of venous thromboembolism, and promotes pulmonary function, especially when respiratory rate is elevated at 24/min. The client is alert and breastfeeding, suggesting stable condition. Prolonged immobility increases risks without benefits in mild-to-moderate infection management.

Choice A rationale

Tachycardia is a common finding in hyperemesis gravidarum due to fluid volume deficit. Significant and persistent vomiting leads to hypovolemia, which triggers a compensatory increase in heart rate to maintain cardiac output and tissue perfusion. The body attempts to compensate for reduced circulating blood volume by increasing the rate at which blood is pumped.

Choice B rationale

Dry mucous membranes are a direct clinical sign of dehydration, which is a hallmark of hyperemesis gravidarum. Prolonged and severe vomiting leads to significant fluid loss, depleting the body's water content. This desiccation is visibly manifested in the oral cavity as dry and sticky mucous membranes, indicating intracellular and extracellular fluid deficit.

Choice C rationale

Poor skin turgor, characterized by skin that remains tented when pinched, is another objective indicator of dehydration. The loss of interstitial fluid due to excessive vomiting reduces the elasticity and plumpness of the skin. This finding reflects a significant depletion of fluid volume within the subcutaneous tissues.

Choice D rationale

Polyuria, meaning excessive urination, is not a typical finding in hyperemesis gravidarum. Instead, severe vomiting and dehydration would lead to oliguria (decreased urine output) as the kidneys attempt to conserve fluid to compensate for the significant fluid losses. The body's priority is fluid retention.

Choice E rationale

Hypertension is generally not associated with hyperemesis gravidarum. Due to significant fluid loss and dehydration, clients with hyperemesis gravidarum are more likely to experience orthostatic hypotension or even profound hypotension as a result of hypovolemia. The decreased circulating blood volume leads to reduced vascular resistance and blood pressure.