A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.

Exhibits

Select the 3 findings that require immediate follow-up.

A. Blood pressure 136/86 mm Hg
  - The blood pressure reading is slightly elevated but not critically high. Postpartum hypertension can be a concern, but this level does not indicate an immediate risk.
  - This reading is consistent with the earlier measurement, suggesting stability.
  - Immediate follow-up is not required unless there is a significant increase or additional symptoms are present.
B. Peripheral edema 2+ bilateral lower extremities
  - Edema is common in the postpartum period due to fluid shifts and should resolve naturally.
  - The consistent 2+ rating indicates no acute change.
  - Monitoring is appropriate, but it does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
C. Lateral deviation of the uterus
  - A laterally deviated uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention.
  - The deviation from the firm, midline position noted earlier could suggest an underlying issue that needs immediate investigation.
  - This finding could lead to complications if not addressed promptly.
D. Breasts soft
  - Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding.
  - There is no change from the earlier assessment.
  - This does not require immediate follow-up as it is a normal finding.
E. Pain rating of 3 on a scale of 0 to 10
  - A pain rating of 3 is mild and manageable, especially considering it was 2 earlier.
  - This slight increase in pain is expected and can be monitored with routine care.
  - It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
F. Uterine tone soft
  - A soft uterine tone postpartum can indicate uterine atony, which can lead to hemorrhage.
  - The change from a previously firm uterus to a soft one is concerning.
  - Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
G. Large amount of lochia rubra
  - A large amount of lochia rubra can be a sign of excessive bleeding.
  - The increase from a moderate amount earlier to a large amount could indicate a hemorrhagic complication.
  - This finding requires immediate follow-up to assess for postpartum hemorrhage.
H. Deep tendon reflexes 1+
  - A deep tendon reflex of 1+ is considered within normal limits.
  - There has been no change from the earlier assessment.
  - This finding does not require immediate follow-up as it is a normal finding.