A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Rationale for correct choices

• Endometritis: The client presents with multiple risk factors for postpartum uterine infection, including cesarean delivery, prolonged rupture of membranes, and high parity. Clinical findings of uterine tenderness, foul-smelling lochia, fever, and tachycardia are classic for endometritis. The markedly elevated WBC count further supports an infectious process rather than normal postpartum changes.

• Uterus and lochia assessment: The uterus is tender to palpation and positioned above the umbilicus, with lochia that is dark brown and foul-smelling, which is abnormal in the postpartum period. Foul-smelling lochia is a hallmark sign of uterine infection due to bacterial overgrowth. Uterine tenderness reflects inflammation of the endometrial lining.

Rationale for incorrect choices

• Mastitis: Although the client reports breast firmness, warmth, and nipple discomfort, these findings are consistent with normal breast engorgement rather than infection. Mastitis typically presents with localized breast redness, unilateral pain, and systemic symptoms such as chills. The uterine findings and foul-smelling lochia are not associated with mastitis.

• Postpartum hemorrhage: Postpartum hemorrhage is characterized by excessive bleeding, hypotension, and signs of hypovolemia, which are not present in this client. The lochia amount is moderate rather than heavy and the hemoglobin level is stable. Although the fundus was initially boggy, it firmed with massage, indicating uterine tone is responsive.

• WBC: Leukocytosis can occur normally in the postpartum period due to physiologic stress and inflammation. While the WBC count is significantly elevated, it is not specific on its own for diagnosing endometritis. Without supporting uterine and lochia findings, an elevated WBC is not the strongest single piece of evidence for this diagnosis.

• Fever: A mild fever can occur postpartum due to breast engorgement, dehydration, or normal inflammatory responses. Fever alone does not localize the source of pathology or confirm uterine infection. When paired with uterine tenderness and foul-smelling lochia, the diagnosis becomes clearer. On its own, fever is insufficient to make the diagnosis.

A. Transport the client to another area of the nursing unit: The first priority during a fire is rescue, ensuring the safety of any individuals in immediate danger. Removing the client from the room prevents exposure to smoke, heat, and flames.

B. Activate the facility's fire alarm system: After ensuring the client’s safety, the nurse must alert others and initiate the facility’s emergency response. Early notification facilitates rapid evacuation and mobilization of fire response teams.

C. Close all nearby windows and doors: Closing doors and windows helps contain the fire, limits oxygen supply to the flames, and reduces the spread of smoke and fire to other areas of the unit.

D. Use the unit's fire extinguisher to attempt to put out the fire: Once people are safe and the alarm is activated, the nurse may attempt to extinguish a small, controllable fire using the appropriate fire extinguisher, following the PASS technique (Pull, Aim, Squeeze, Sweep).