A nurse has been monitoring a client who gave birth vaginally 8 hours ago.

Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.

Choice A rationale
Jitteriness is a common sign of hypoglycemia in newborns. Newborns whose mothers had gestational diabetes are at an increased risk of developing hypoglycemia shortly after birth. Other signs of neonatal hypoglycemia can include poor feeding, lethargy, and seizures.
Choice B rationale
Increased muscle tone is not typically associated with hypoglycemia in newborns. However, decreased muscle tone can be a sign of severe hypoglycemia.
Choice C rationale
Abdominal distention is not typically associated with hypoglycemia in newborns. However, it can be a sign of other conditions, such as gastrointestinal obstruction or sepsis.
Choice D rationale
Petechiae, or small red or purple spots on the skin caused by bleeding into the skin, are not typically associated with hypoglycemia in newborns. However, they can be a sign of other conditions, such as infection or a bleeding disorder.