A nurse is collecting data from a client who gave birth 12 hr ago.
The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus.
Which of the following actions should the nurse take first?

As a maternity-prepared nurse, the nurse understands that the client’s elevated WBC count is A. Expected due to postpartum recovery and A. Expected to decrease to normal levels in about one week postpartum.

Elevated WBC counts are common in the immediate postpartum period due to the body’s response to labor and delivery. These levels typically return to normal within the first week postpartum.

The elevated white blood cell (WBC) count in the immediate postpartum period is a normal physiological response to labor and delivery. Here’s why:

1. Body’s Response to Labor: During labor, the body undergoes significant stress and physical exertion, which naturally leads to an increase in WBC count.This is part of the body’s inflammatory response to the physical trauma of childbirth.
2. Postpartum Changes: After delivery, the body continues to experience changes as it begins to recover.The elevated WBC count helps the body to heal and protect against potential infections during this vulnerable period.
3. Expected Decrease: Typically, the WBC count peaks within the first 24 hours postpartum and then gradually decreases, returning to normal levels within the first week. This decrease aligns with the body’s recovery process as the immediate postpartum inflammation subsides.

In summary, the elevated WBC count is expected due to the body’s natural response to childbirth and is anticipated to normalize within about a week postpartum.

Choice A rationale

A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.

Choice B rationale

Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.

Choice C rationale

A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.

Choice D rationale

A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.