A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1. Nurses’ Notes.
0700:. Exhibit 2. 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.
Vital Signs.
0700:. Temperature 36.2° C (97.2° F). Pulse rate 80/min.
Respiratory rate 16/min.
Blood pressure 136/82 mm Hg. Pulse oximetry 999%. 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.
A.
Peripheral edema 2+ bilateral lower extremities.
B.
Lateral deviation of the uterus.
C.
Large amount of lochia rubra.
D.
Uterine tone soft.
The correct answer and Explanation is :
The three findings that require immediate follow-up are:
B. Lateral deviation of the uterus
C. Large amount of lochia rubra
D. Uterine tone soft
Explanation:
- Lateral deviation of the uterus (B):
A uterus that is laterally deviated and 1 cm above the umbilicus suggests bladder distention. A full bladder can prevent the uterus from contracting properly, leading to an increased risk of postpartum hemorrhage. The nurse should assist the patient in emptying her bladder, which can help the uterus return to its normal position and improve uterine tone. - Large amount of lochia rubra (C):
Lochia is the vaginal discharge that occurs after childbirth, progressing from red (lochia rubra) to pink (lochia serosa) to white (lochia alba) over time. While a moderate amount of lochia rubra is expected in the immediate postpartum period, a large amount indicates possible excessive bleeding. This is a concerning finding, especially when accompanied by a soft uterus, which could indicate uterine atony and increase the risk of postpartum hemorrhage. This requires immediate assessment and intervention. - Uterine tone soft (D):
A soft uterus (uterine atony) is a significant risk factor for postpartum hemorrhage, the leading cause of maternal morbidity and mortality in the postpartum period. The uterus should be firm and contracted to prevent excessive bleeding. A soft, boggy uterus suggests that it is not contracting effectively, which can lead to excessive blood loss. Immediate actions such as fundal massage, encouraging the client to empty her bladder, and possibly administering uterotonic medications (e.g., oxytocin) are necessary to restore uterine tone.
Peripheral edema (A) is a common finding in the postpartum period and does not require immediate intervention unless accompanied by other signs of complications, such as significantly elevated blood pressure or signs of deep vein thrombosis. Therefore, it is not one of the immediate concerns in this scenario.