A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.

Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.

Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.

Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.

Choice a) reason: Pelvic pain is a common symptom of endometritis. The pain is typically located in the lower abdomen and may be associated with uterine tenderness upon physical examination. This symptom, especially when combined with other signs such as fever and foul-smelling lochia, strongly suggests the need for further evaluation for endometritis.

Choice b) reason: Hematuria, or blood in the urine, is not a typical symptom of endometritis. While it could be a sign of other postpartum complications, such as urinary tract infections or bladder injury during childbirth, it does not directly indicate endometritis.

Choice c) reason: A localized area of breast tenderness is more indicative of a breast infection, such as mastitis, especially if associated with breastfeeding. It is not a symptom of endometritis, which affects the uterus and not the breasts.

Choice d) reason: While foul-smelling lochia can be a sign of endometritis, the key is the presence of a foul odor. A moderate amount of dark red lochia alone, without a foul odor, is a normal finding in the immediate postpartum period. It's the transition from rubra (red) to serosa (pink/brown) to alba (yellow/white) that is expected as the uterus heals.