# A nurse is assessing a postpartum client 48 hours after cesarean delivery. Which assessment finding would be the priority concern indicating a possible postpartum infection?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a postpartum client 48 hours after cesarean delivery. Which assessment finding would be the priority concern indicating a possible postpartum infection?

## 보기

1. Temperature of 101.2°F (38.4°C) with chills and malaise **✔ 정답**
2. Lochia rubra with small clots and mild cramping
3. Breast tenderness with slight engorgement
4. Perineal edema with mild discomfort during urination

**정답: 1**

## 해설

Temperature >100.4°F after 24 hours postpartum with systemic symptoms indicates infection requiring immediate attention. Other findings are normal postpartum variations.

## 심화 해설

Clinical Reasoning & Priority Setting

This question tests your ability to differentiate between expected postpartum changes and findings that signal a potentially serious complication. After a cesarean delivery, the nurse must be vigilant for signs of infection, as surgical incisions and the uterine cavity provide direct pathways for pathogens.

The priority concern is a temperature of 101.2°F (38.4°C) with chills and malaise. In the postpartum period, a low-grade fever can sometimes occur due to dehydration or the normal inflammatory response, particularly with breast engorgement. However, a temperature of 100.4°F (38.0°C) or higher after the first 24 hours, especially when accompanied by systemic symptoms like chills and malaise, is a cardinal sign of postpartum infection [1]. The US has a significant rate of postpartum complications, and the emergency department is often the primary access point for urgent care during this vulnerable period, making early recognition of such signs critical [1]. This presentation raises immediate concern for endometritis, a well-described cause of postdelivery morbidity [2], or a surgical site infection. The combination of a significant fever and systemic symptoms indicates a systemic inflammatory response that requires prompt investigation and intervention to prevent maternal morbidity [1,2].

Analysis of Other Options

-   Lochia rubra with small clots and mild cramping is an expected finding at 48 hours postpartum. The cramping is associated with uterine involution, and small clots are common as the uterus contracts and sheds its lining.

-   Breast tenderness with slight engorgement is a normal physiological process as milk production transitions from colostrum to mature milk around this time. While engorgement can cause a mild, transient temperature elevation, it would not typically cause a fever of 101.2°F with chills.

-   Perineal edema with mild discomfort during urination is an expected finding after a vaginal delivery, but this client had a cesarean delivery. Even if she labored beforehand, localized perineal discomfort without fever or other signs of infection is not the priority over a systemic febrile response. The fever and chills signal a systemic process, which takes precedence over localized discomfort in the nursing assessment hierarchy.References (research sources)

- [1]Postpartum Complications Modified TBL.Research articleLamparter LE. (2026) · DOI: 10.5070/m5.52264

- [2]Not Just a Cold Sore: Postpartum Herpes Simplex Virus Endometritis.Research articleMoore O, Cottrell J. (2026) · DOI: 10.1155/crog/7459192

## 임상 시나리오

Clinical Guide: Early Recognition of Postpartum Infection

Postpartum infections remain a leading cause of maternal morbidity. Early recognition and intervention, particularly in the first 72 hours after cesarean delivery, are critical for preventing sepsis and readmission.

Key Assessment Findings

- **Cardinal Sign:** Oral temperature ≥ 100.4°F (38.0°C) on any two of the first 10 days postpartum, excluding the first 24 hours. A single spike with systemic symptoms (chills, malaise) warrants immediate investigation.

- **Common Sources:** Endometritis (uterine tenderness, foul-smelling lochia), surgical site infection (erythema, purulent drainage from incision), mastitis (unilateral breast erythema, pain), and urinary tract infection (dysuria, urgency).

- **Systemic Indicators:** Tachycardia, rigors, and malaise often accompany the fever and suggest a systemic inflammatory response.

Nursing Actions & Priority Setting

- **Immediate Actions:** Obtain blood cultures, complete blood count, and lactate level. Notify the provider immediately with a full set of vital signs and assessment findings.

- **Focused Assessment:** Inspect the cesarean incision for signs of infection, palpate the uterine fundus for tenderness, and assess lochia for odor and consistency. Auscultate lung sounds and assess for calf tenderness to rule out other sources.

- **Patient Education:** Instruct the patient to report any fever, chills, increased pain, or foul-smelling discharge immediately. Emphasize the importance of hand hygiene and incision care.

Differentiating Expected from Abnormal Findings

- **Expected:** Mild cramping with lochia rubra, slight breast engorgement, perineal edema, and a low-grade temperature (< 100.4°F) in the first 24 hours due to dehydration or breast engorgement.

- **Abnormal:** Fever ≥ 100.4°F after 24 hours, foul-smelling lochia, purulent wound drainage, localized breast erythema with flu-like symptoms, or dysuria with flank pain.

## 핵심 개념

- **Endometritis** — An infection of the uterine lining, a common cause of postpartum fever and morbidity, often presenting with fever, chills, and malaise.
- **Lochia Rubra** — The normal vaginal discharge after delivery consisting of blood and decidual debris, lasting for the first 3-4 days postpartum.
- **Postpartum Infection** — An infection occurring within the first six weeks after delivery, commonly signaled by a fever of 100.4°F (38.0°C) or higher after the first 24 hours.

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