A nurse is assisting with the care of a postpartum female client who delivered vaginally 8 hours ago in the maternity unit.

Exhibits

Select the 3 findings that require immediate follow-up.

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.

Choice B rationale:

Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.

Choice C rationale:

A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.

Choice D rationale:

A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.

Choice E rationale:

Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.

Choice F rationale:

A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.

Choice G rationale:

A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.

Choice H rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.