A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?

Choice A rationale

Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.

Choice B rationale

A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.

Choice C rationale

A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.

Choice D rationale

A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.

Choice E rationale

Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.

Choice F rationale

Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.

Choice G rationale

A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.

Choice H rationale

Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly. .

Based on the provided information, here’s the completed diagram:

Potential Condition

• D. Endometritis

Actions to Take

• A. Administer broad-spectrum antibiotics
• D. Administer analgesics

Parameters to Monitor

• A. Lochia amount and odor
• B. Temperature

Explanation of Other Conditions

1. Deep vein thrombosis (DVT):
   • Reasoning: The client has bilateral edema without pain, warmth, or tenderness, which are typical signs of DVT. Additionally, the primary symptoms (malaise, chills, fever, foul-smelling lochia) are more indicative of an infection like endometritis.
2. Urinary tract infection (UTI):
   • Reasoning: The client is voiding frequently without difficulty, and there are no specific urinary symptoms like dysuria or urgency. The presence of foul-smelling lochia and a boggy, tender uterus points more towards endometritis.
3. Engorgement:
   • Reasoning: While the client’s breasts are firm and heavy, she denies nipple discomfort, and the primary symptoms (fever, chills, malaise, foul-smelling lochia) are more consistent with an infection rather than simple breast engorgement.