A nurse is assessing a client who is 1 hour postpartum.
Which of the following findings should the nurse report to the provider?

Temperature 37.7° C (99.9° F).

Boggy fundus.

Lochia rubra with small clots.

Minimal perineal edema.

Answer and Explanation

The Correct Answer is B

Choice A rationale

A temperature of 37.7° C (99.9° F) in the immediate postpartum period is a relatively common and often benign finding, typically within normal limits or indicating mild dehydration or exertion from labor. A slight elevation is not usually a cause for immediate concern unless accompanied by other signs of infection, which would warrant further investigation. Normal range is 36.5° C to 37.5° C (97.7° F to 99.5° F).

Choice B rationale

A boggy fundus is a significant finding that the nurse should report immediately. A boggy, soft uterus indicates uterine atony, which means the uterine muscles are not contracting effectively. This significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.

Choice C rationale

Lochia rubra with small clots is considered a normal finding in the immediate postpartum period. Lochia rubra is the initial dark red discharge consisting of blood, decidual tissue, and mucus. Small clots are expected as blood clots and detaches from the uterine wall, reflecting normal uterine involution.

Choice D rationale

Minimal perineal edema is a normal and expected finding after vaginal delivery. The trauma of childbirth often results in some degree of swelling in the perineal area. "Minimal" edema indicates that the swelling is not excessive and does not suggest a complication requiring immediate reporting to the provider.

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Correct Answer is C

Explanation

Choice A rationale

Increased leukorrhea, or vaginal discharge, is a common and normal physiological finding during pregnancy due to increased estrogen levels and blood flow to the vaginal area. This increase in discharge helps prevent ascending infections. Unless accompanied by itching, odor, or color changes, it typically does not indicate a problem.

Choice B rationale

Urinary frequency is a common symptom in late pregnancy, particularly in the third trimester. It results from the enlarging uterus compressing the bladder, reducing its capacity, and increasing renal blood flow and glomerular filtration rate, leading to increased urine production. It is a normal physiological adaptation.

Choice C rationale

A persistent headache in a pregnant client, especially in the third trimester, is a priority to assess further because it can be a sign of preeclampsia, a serious hypertensive disorder of pregnancy. Other symptoms of preeclampsia include visual disturbances, right upper quadrant pain, and proteinuria. Early identification is crucial for intervention.

Choice D rationale

Insomnia is a common complaint during the third trimester of pregnancy. It can be attributed to various factors such as physical discomfort, frequent urination, fetal movements, anxiety, and hormonal changes. While bothersome, it is generally considered a normal, though often challenging, aspect of late pregnancy.

A. The bladder is distended upon palpation. B. The uterine fundus is 2 cm above the umbilicus. C. The client does not feel the urge to urinate. D. The client urinates 30 mL/hr.

Correct Answer is D

Explanation

A. The bladder is distended upon palpation: A distended bladder suggests urinary retention, not effective voiding. This may impair uterine contraction and increase the risk of hemorrhage.
B. The uterine fundus is 2 cm above the umbilicus: A high-rising fundus may indicate a full bladder that is displacing the uterus, often due to incomplete voiding.
C. The client does not feel the urge to urinate: Lack of urge may indicate altered bladder sensation, a potential complication after catheter removal and childbirth.
D. The client urinates 30 mL/hr: Urine output of ≥30 mL/hr is considered adequate and reflects effective voiding and kidney function, especially in the postpartum period.

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A nurse is assessing a client who is 1 hour postpartum.
Which of the following findings should the nurse report to the provider?