1. A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Exhibit 1

Nurses' Notes

0700:

Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.

1100:

Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.

Exhibit 2

0700:

Temperature 36.2" C (97.2" F) Pulse rate 80/min

Respiratory rate 16/min

Blood pressure 136/82 mm Hg

Pulse oximetry 99%

1100:

Temperature 37.2° C (99.0° F)

Pulse rate 85/min

Respiratory rate 18/min

Blood pressure 136/86 mm Hg

Pulse oximetry 100%

Select the 3 findings that require immediate follow-up.

. Lochia rubra with small clots:

Lochia rubra is the normal vaginal discharge occurring after childbirth, consisting of blood, mucus, and uterine tissue. It is expected for lochia to be present in the immediate postpartum period, and small clots are also considered normal as long as they are not excessive in size. Therefore, this finding is within the expected range for a client who is 1 hour postpartum and does not require immediate reporting to the provider.

B. Minimal perineal edema:

Perineal edema, or swelling in the perineal area, can be common after childbirth, particularly following vaginal delivery or if there was perineal trauma during labor. Some degree of perineal edema is generally expected in the immediate postpartum period and may resolve with time and appropriate care. As long as the edema is minimal and not causing significant discomfort or obstructing the assessment, it is not typically a cause for immediate concern or reporting to the provider.

C. Boggy fundus:

A boggy fundus refers to a uterus that feels soft and mushy instead of firm and well-contracted. It suggests uterine atony, which is a significant concern in the postpartum period as it can lead to excessive bleeding and postpartum hemorrhage. Therefore, a boggy fundus should be reported promptly to the provider so that interventions can be initiated to address the uterine atony and prevent complications.

D. Temperature 37.7°C (99.9°F):

A temperature of 37.7°C (99.9°F) is slightly elevated but may still fall within the normal range for the immediate postpartum period. While fever can indicate infection, a single temperature reading alone may not be sufficient to confirm an infection. It is important for the nurse to continue monitoring the client's temperature and assess for other signs and symptoms of infection before reporting to the provider. Therefore, this finding does not necessarily warrant immediate reporting unless accompanied by other concerning symptoms suggestive of infection.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client: These findings represent Braxton Hicks contractions, which are a physiological occurrence during the third trimester of pregnancy. They do not typically cause fetal heart rate decelerations or indicate placental insufficiency at 35 weeks. Their presence is considered a normal variant during an antepartal nonstress test.

B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period: A reactive nonstress test requires at least 2 accelerations of 15 beats per minute above baseline lasting 15 seconds each within 20 minutes. An acceleration lasting only 10 seconds at 35 weeks gestation is insufficient to meet the criteria for fetal well-being. This non-reactive result necessitates further evaluation through a biophysical profile or contraction stress test.

C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period: This description actually identifies a negative contraction stress test, which is a reassuring finding indicating adequate fetal oxygenation during uterine activity. The absence of late decelerations suggests that the uteroplacental unit is functioning effectively under the stress of contractions. It does not indicate a need for further diagnostic intervention.

D. Three fetal movements perceived by the client in a 20-min testing period: Fetal movement during the testing period is a positive sign of neuromuscular integrity and fetal oxygenation. While movement is essential, the nonstress test specifically evaluates the fetal heart rate's sympathetic response to that movement. As long as these movements are accompanied by appropriate accelerations, no further testing is indicated.