A nurse is assisting with the care of a postpartum female client who delivered vaginally 8 hours ago in the maternity unit.
Exhibit 1: Vital Signs
0700:
- Temperature: 36.2°C (97.2°F)
- Heart rate: 80/min
- Respiratory rate: 16/min
- Blood pressure: 136/82 mm Hg
1100:
- Temperature: 37.2°C (99.0°F)
- Heart rate: 85/min
- Respiratory rate: 18/min
- Blood pressure: 136/86 mm Hg
- Pulse oximetry: 99%
Exhibit 2: Nurses' Notes
0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
Querry
Select the 3 findings that require immediate follow-up.
Deep tendon reflexes 1+
Lateral deviation of the uterus
Blood pressure 136/86 mm Hg
Pain rating of 3 on a scale of 0 to 10
Breasts soft
Uterine tone soft
Large amount of lochia rubra
Peripheral edema 2+ in bilateral lower extremities
Correct Answer : B,F,G
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.
Choice B rationale:
Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.
Choice C rationale:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.
Choice D rationale:
A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.
Choice E rationale:
Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.
Choice F rationale:
A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.
Choice G rationale:
A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.
Choice H rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.
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Explanation
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Choice B rationale
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Choice C rationale
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Choice D rationale
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Correct Answer is B
Explanation
Choice A rationale
A client whose labor lasted for 6 hours is not necessarily a priority unless other complications are present. Duration of labor alone does not indicate an urgent need for immediate attention postpartum.
Choice B rationale
A client who received magnesium sulfate during labor should be seen first due to the potential for serious side effects such as respiratory depression, hypotonia in the newborn, and maternal complications. Magnesium sulfate is used to prevent seizures in clients with preeclampsia and requires close monitoring.
Choice C rationale
A client with a history of oligohydramnios needs monitoring, but this condition alone does not take precedence over the immediate postpartum risks associated with magnesium sulfate.
Choice D rationale
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