# Situation: The nurse cares for mothers on the postpartum ward and in the postpartum clinic of a government hospital. At the start of the shift, the nurse reviews four postpartum clients: Client 1 | Day 1 after vaginal birth | Temperature 37.8 °C, pulse 88/min, respirations 18/min, blood pressure 118/74 mmHg | White cell count 19,000/µL, fundus firm Client 2 | Day 3 after vaginal birth | Temperature 38.2 °C, pulse 94/min, respirations 18/min, blood pressure 116/72 mmHg | Burning on urination and frequency Client 3 | Day 2 after cesarean birth for prolonged labor | Temperature 37.6 °C, pulse 124/min, respirations 26/min, blood pressure 94/60 mmHg (120/78 mmHg on admission) | Uterus tender, urine output 20 mL/hour for 2 hours Client 4 | Day 3 after cesarean birth, on treatment for left calf deep vein thrombosis | Temperature 37.4 °C, pulse 90/min, respirations 18/min, blood pressure 122/80 mmHg | Calf swelling unchanged Which client should the nurse assess FIRST?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse cares for mothers on the postpartum ward and in the postpartum clinic of a government hospital.

At the start of the shift, the nurse reviews four postpartum clients:
Client 1 | Day 1 after vaginal birth | Temperature 37.8 °C, pulse 88/min, respirations 18/min, blood pressure 118/74 mmHg | White cell count 19,000/µL, fundus firm
Client 2 | Day 3 after vaginal birth | Temperature 38.2 °C, pulse 94/min, respirations 18/min, blood pressure 116/72 mmHg | Burning on urination and frequency
Client 3 | Day 2 after cesarean birth for prolonged labor | Temperature 37.6 °C, pulse 124/min, respirations 26/min, blood pressure 94/60 mmHg (120/78 mmHg on admission) | Uterus tender, urine output 20 mL/hour for 2 hours
Client 4 | Day 3 after cesarean birth, on treatment for left calf deep vein thrombosis | Temperature 37.4 °C, pulse 90/min, respirations 18/min, blood pressure 122/80 mmHg | Calf swelling unchanged
Which client should the nurse assess FIRST?

## 보기

1. Client 4
2. Client 3 **✔ 정답**
3. Client 1
4. Client 2

**정답: 2**

## 해설

Client 3 has a pulse above 110/min, respirations above 24/min, falling blood pressure, and low urine output after a cesarean for prolonged labor, with a tender uterus: warning signs of puerperal sepsis from endometritis. Fever is not required, and tachycardia is often the first sign, so her near-normal temperature is the trap. Client 2 has the highest temperature, but her stable vital signs and urinary symptoms point to cystitis, which needs treatment but is less urgent.

## 심화 해설

Priority setting using maternal early warning signs

The first step is to recognize that postpartum vital sign changes must be interpreted against the patient’s own baseline and the clinical context of delivery. Client 3 demonstrates a pattern of hemodynamic instability and end-organ hypoperfusion that is consistent with evolving puerperal sepsis, even though her temperature is only mildly elevated.

Why Client 3 is the priority

Client 3 is on Day 2 after a cesarean birth performed for prolonged labor. Prolonged labor and cesarean delivery both increase the risk of intrauterine infection and subsequent endometritis, which can progress to sepsis. Her vital signs show:

- Pulse 124/min — tachycardia above 110/min

- Respirations 26/min — tachypnea above 24/min

- Blood pressure 94/60 mmHg — a significant drop from her admission baseline of 120/78 mmHg

- Urine output 20 mL/hour for 2 hours — oliguria indicating reduced renal perfusion

- Uterine tenderness — a localized sign pointing to endometritis as the likely infectious source

Tachycardia is frequently the earliest and most reliable sign of maternal sepsis, often preceding fever or a dramatic fall in blood pressure. The near-normal temperature of 37.6 °C can mislead clinicians because normal pregnancy-related physiologic changes and the postpartum inflammatory response may blunt or mask fever. The combination of tachycardia, tachypnea, hypotension relative to baseline, and oliguria indicates that this client is already showing signs of organ dysfunction, which meets the definition of sepsis rather than a localized infection.

Watch out! A single abnormal vital sign may not trigger concern, but the clustering of tachycardia, tachypnea, relative hypotension, and low urine output is a maternal early warning sign pattern that demands immediate bedside evaluation and intervention.

Why the other clients are lower priority

| Client | Key findings | Interpretation | Priority rationale |
| --- | --- | --- | --- |
| Client 1 | Day 1 vaginal birth; temp 37.8 °C; WBC 19,000/µL; firm fundus | Mild temperature elevation and leukocytosis are common in the immediate postpartum period due to physiologic stress and involution; firm fundus suggests adequate uterine contraction | No hemodynamic instability or organ dysfunction; monitor but not the first to assess |
| Client 2 | Day 3 vaginal birth; temp 38.2 °C; burning on urination and frequency | Fever with urinary symptoms points to cystitis; vital signs otherwise stable | Requires treatment, but localized urinary tract infection without systemic instability is less urgent than suspected sepsis |
| Client 4 | Day 3 cesarean; on treatment for left calf deep vein thrombosis; calf swelling unchanged | Stable vital signs; no new respiratory symptoms or hemodynamic changes; already receiving anticoagulation | Monitor for pulmonary embolism, but current presentation is stable |

Clinical reasoning for the licensure exam

In maternal sepsis, the physiologic adaptations of pregnancy and the postpartum period can obscure classic signs. The most important clinical pearl is that fever is not required to diagnose sepsis; tachycardia, tachypnea, altered mental status, hypotension, and oliguria are more actionable warning signs. When a postpartum client has a tender uterus after cesarean delivery for prolonged labor, the nurse should immediately suspect endometritis as the source and recognize that hemodynamic instability signals progression toward septic shock.

Key point! Prioritization is based on the risk of imminent deterioration. Client 3 shows evidence of distributive shock physiology from a likely intrauterine source, while Clients 1, 2, and 4 have localized or expected postpartum findings without current hemodynamic compromise [1][2][3].References (research sources)

- [1]Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis.Research articleShields A, Shields A, de Assis V, Halscott T. (2021) · DOI: 10.1097/aog.0000000000004471

- [2]Obstetric Sepsis: A Review Article.Research articleNayak AH, Khade SA. (2022) · DOI: 10.1007/s13224-022-01706-y

- [3]Sepsis and Septic Shock During Pregnancy and Postpartum.Research articleBauer ME, Pacheco LD. (2025) · DOI: 10.1097/aog.0000000000005991

## 임상 시나리오

Postpartum Early Warning SignsRecognizing Maternal Sepsis Before Fever Appears
In postpartum patients, tachycardia above 110/min is often the earliest sign of puerperal sepsis, preceding fever or hypotension. Always compare vital signs to the patient's own baseline.

A cesarean birth after prolonged labor increases the risk of endometritis and subsequent sepsis. Uterine tenderness is a localized sign pointing to the infectious source.

Red flags include tachypnea above 24/min, hypotension relative to baseline, and oliguria below 30 mL/hour for 2 hours, indicating end-organ hypoperfusion.

CautionA near-normal temperature does not rule out sepsis. Postpartum inflammatory changes can mask fever, so rely on the full clinical picture—especially tachycardia and urine output.

## 핵심 개념

- **Puerperal sepsis** — Systemic infection originating from the genital tract within 42 days after birth, often preceded by endometritis; tachycardia is an early sign.
- **Maternal early warning signs** — Criteria including pulse >110/min, respirations >24/min, hypotension relative to baseline, and oliguria that indicate clinical deterioration.
- **Endometritis** — Postpartum uterine infection, more common after cesarean birth and prolonged labor, presenting with uterine tenderness and fever or tachycardia.
- **Oliguria** — Urine output less than 30 mL/hour, indicating reduced renal perfusion and possible end-organ hypoperfusion in sepsis.
- **Tachycardia** — Heart rate above 110/min; often the earliest and most reliable sign of maternal sepsis, preceding fever or hypotension.

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