A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

A) Clean the perineal area from front to back:

This is correct. Instructing the client to clean the perineal area from front to back helps prevent the introduction of fecal bacteria into the vaginal area, reducing the risk of perineal infection.

B) Blot the perineal area dry after cleansing:

This is correct. Instructing the client to blot the perineal area dry after cleansing helps remove excess moisture, which can promote bacterial growth and increase the risk of infection.

D) Perform hand hygiene before and after voiding:

This is correct. Performing hand hygiene before and after voiding is essential to reduce the risk of introducing bacteria from the hands to the perineal area, which can lead to infection.

E) Wash the perineal area using a squeeze bottle of warm water after each voiding:

This is correct. Washing the perineal area with warm water using a squeeze bottle after each voiding helps cleanse the area without causing irritation or trauma, promoting perineal hygiene and reducing the risk of infection.

C) Apply ice packs to the perineal area several times daily:

This is incorrect. While applying ice packs to the perineal area can help reduce swelling and discomfort after vaginal delivery, it is not specifically aimed at reducing perineal infection. Cold therapy is more focused on providing comfort and promoting healing of any perineal trauma rather than preventing infection.

A) Notify the client's provider:

There is no indication to notify the provider at this time. The presence of lochia rubra with small clots and a firm, midline fundus at the umbilicus indicates typical postpartum bleeding and uterine involution. This finding does not warrant immediate notification of the provider.

B) Encourage the client to empty her bladder:

Encouraging the client to empty her bladder is essential for promoting uterine contractions and preventing uterine atony. However, in this scenario, the fundus is already midline and firm, suggesting that bladder distension is not the cause of the excessive bleeding. While voiding may help, it is not the priority action.

C) Increase the frequency of fundal massage:

Increasing the frequency of fundal massage may not be necessary in this situation since the fundus is already midline and firm, indicating adequate uterine contractions. Fundal massage is typically performed if the fundus is boggy or if there is excessive bleeding.

D) Document the findings and continue to monitor the client:

This is the correct action. Documenting the assessment findings, including the amount and character of lochia, presence of clots, and fundal height, is essential for ongoing monitoring and evaluation of the client's postpartum recovery. Continuing to monitor the client allows the nurse to detect any changes in condition that may require further intervention.