A nurse is assessing a client who is 12 hours postpartum and received spinal anesthesia for a cesarean birth.
Which of the following findings requires immediate intervention by the nurse?

Choice A rationale

Accumulation of flatulence can cause abdominal discomfort after a cesarean birth, but it does not directly stimulate uterine contractions leading to afterpains. Afterpains are specifically related to the involution of the uterus, not gastrointestinal motility.

Choice B rationale

Breastfeeding stimulates the release of oxytocin from the posterior pituitary gland. Oxytocin is a powerful uterotonic hormone that causes the uterus to contract to its pre-pregnant size. These contractions are experienced as afterpains, especially in multiparous women whose uterine muscles may have less tone.

Choice C rationale

While some medications administered after birth can have side effects, severe cramps or afterpains are primarily a physiological response to uterine involution and the hormonal changes associated with breastfeeding, rather than a direct adverse effect of medication.

Choice D rationale

Healing of the abdominal incision after a C-section causes incisional pain, which is distinct from the cramping sensation of afterpains. Afterpains are specifically due to uterine contractions, not the healing process of the abdominal wall.

Choice A rationale

Deep tendon reflexes of +1 are hypoactive reflexes, indicating decreased neurological excitability. In preeclampsia, central nervous system irritability is a key feature, often leading to hyperreflexia, which would be documented as +2, +3, or +4. Therefore, +1 reflexes are inconsistent with preeclampsia.

Choice B rationale

3+ protein in the urine indicates significant proteinuria, which is a hallmark sign of preeclampsia. The kidneys are affected in preeclampsia, leading to increased excretion of protein in the urine.

Choice C rationale

A blood pressure of 148/98 mm Hg is elevated and falls within the diagnostic criteria for preeclampsia, which is hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) that develops after 20 weeks of gestation along with proteinuria or other signs of end-organ damage.

Choice D rationale

Pitting sacral edema, or swelling in the sacral area that leaves a pit when pressed, is a common finding in preeclampsia due to fluid retention and increased capillary permeability.