“I’m Not Feeling Right Since Having My Baby”
Assignment Instructions
Read the following unfolding case carefully. Additional information is revealed as the patient’s condition changes.
Answer all seven questions using current evidence-based clinical guidelines (ACOG, CDC, SMFM, and current literature).
Requirements
- APA 7th edition formatting
- Minimum of three current scholarly references
- Provide evidence-based rationales for all answers
- Total length: 3 pages (excluding title and references)
Learning Objectives
Upon successful completion, the student will be able to:
- Differentiate normal postpartum recovery from postpartum infection.
- Recognize postpartum endometritis and early maternal sepsis.
- Develop appropriate differential diagnoses.
- Interpret laboratory and diagnostic findings.
- Determine appropriate disposition.
- Develop an evidence-based treatment plan.
- Describe the FNP’s role in recognizing and managing postpartum complications.
Patient Case
A 29-year-old G2P2 female presents to your family practice clinic for an urgent same-day appointment.
She is 14 days postpartum following a vaginal delivery.
She tells you,
“I’ve been feeling worse every day. I thought I’d be getting better, but now I have chills and this awful pelvic pain.”
She reports:
- Fever for two days
- Increasing lower abdominal pain
- Chills
- Fatigue
- Foul-smelling vaginal discharge
- Poor appetite
- Mild headache
She has been taking ibuprofen every six hours with minimal relief.
Obstetric History
- Vaginal delivery at 39 weeks
- Labor lasted 22 hours
- Manual removal of placenta because membranes were retained
- Second-degree perineal laceration
- Breastfeeding successfully
- No postpartum visit yet
Past Medical History
- Obesity (BMI 34 kg/m²)
- Diet-controlled gestational diabetes
No medication allergies.
Physical Examination
General
Appears ill, tired, and uncomfortable.
Vital Signs
| Vital Sign | Patient | Normal |
| Temperature | 102.1°F (38.9°C) | 97–99°F (36.1–37.2°C) |
| Heart Rate | 116 bpm | 60–100 bpm |
| Respiratory Rate | 22/min | 12–20/min |
| Blood Pressure | 102/66 mmHg | <120/80 mmHg |
| Oxygen Saturation | 98% RA | ≥95% |
Physical Examination
Abdomen
- Moderate suprapubic tenderness
- No rebound
- Mild guarding
Pelvic Examination
- Purulent foul-smelling lochia
- Significant uterine fundal tenderness
- Cervix slightly dilated
- No excessive vaginal bleeding
- Perineal laceration healing appropriately
Laboratory Results
| Laboratory | Patient | Normal Range |
| WBC | 19,400/mm³ | 4,500–11,000/mm³* |
| Neutrophils | 88% | 40–70% |
| Hemoglobin | 10.1 g/dL | 12–16 g/dL |
| Hematocrit | 31% | 36–46% |
| Platelets | 305,000/mm³ | 150,000–400,000/mm³ |
| Lactate | 2.8 mmol/L | 0.5–2.0 mmol/L |
| C-Reactive Protein | 18 mg/dL | <0.5 mg/dL |
| Procalcitonin | 1.9 ng/mL | <0.1 ng/mL |
| Urinalysis | Trace leukocytes; nitrites negative; bacteria absent | Negative |
| Blood Cultures | Pending | Negative |
*Note: Mild leukocytosis may persist postpartum, but this degree of elevation accompanied by fever and uterine tenderness is concerning for infection.
Imaging
Transvaginal Ultrasound
- Thickened endometrial lining
- Small amount of intrauterine fluid
- No retained products of conception
- No tubo-ovarian abscess
The Case Progresses
Thirty minutes later, while awaiting EMS transport:
Repeat Vital Signs
| Vital Sign | Patient | Normal |
| Temperature | 102.4°F | 97–99°F |
| Heart Rate | 128 bpm | 60–100 bpm |
| Respiratory Rate | 28/min | 12–20/min |
| Blood Pressure | 90/58 mmHg | <120/80 mmHg |
| Oxygen Saturation | 97% | ≥95% |
The patient states,
“I feel dizzy… I think I’m going to pass out.”
Her skin is pale and diaphoretic.
Capillary refill is delayed.
Questions
Question 1 (15 points)
What is the most likely diagnosis?
Support your diagnosis using at least four findings from the case.
Question 2 (15 points)
Develop a prioritized differential diagnosis.
Include at least four possible diagnoses and explain why each is either supported or ruled out.
Question 3 (15 points)
The patient’s condition deteriorates while in your office.
As the Family Nurse Practitioner, describe your immediate priorities of care before transfer to the Emergency Department.
Question 4 (15 points)
Interpret the laboratory and ultrasound findings.
Explain how each abnormal finding supports the diagnosis and influences management.
Question 5 (20 points)
Develop a comprehensive evidence-based treatment plan.
Include:
- Appropriate disposition
- Intravenous fluids
- Blood cultures
- Antibiotic therapy (drug, dose, route, and rationale)
- Additional laboratory testing
- Monitoring
- Consultation
- Sepsis management
Question 6 (10 points)
Develop a discharge education plan after successful hospitalization.
Include:
- Medication adherence
- Breastfeeding
- Warning signs
- Follow-up
- Prevention of future complications
Question 7 (10 points)
Discuss the role of the Family Nurse Practitioner in recognizing postpartum infections.
Include:
- Early recognition
- Collaboration
- Patient advocacy
- Maternal sepsis screening
- Evidence-based practice
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