A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

Choice A rationale

Hypertension is not a common adverse effect of epidural anesthesia. In fact, epidurals can cause hypotension due to the blockade of sympathetic nerves.

Choice B rationale

Tachypnea is not typically associated with epidural anesthesia. Common side effects include low blood pressure and headache.

Choice C rationale

Tachycardia is not a common adverse effect of epidural anesthesia. More common side effects include low blood pressure and urinary retention.

Choice D rationale

Fever is a known adverse effect of epidural anesthesia. It can occur due to the body’s response to the epidural procedure.

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal and do not indicate any immediate concern. Reflexes are graded on a scale from 0 to 4+, with 2+ being normal. A 1+ reflex is slightly diminished but can be normal in some individuals.

Choice B rationale:

A pain rating of 3 on a scale of 0 to 10 is relatively low and manageable. Postpartum pain is expected, and a rating of 3 does not indicate severe pain that requires immediate intervention.

Choice C rationale:

The blood pressure reading of 136/86 mm Hg is slightly elevated but not alarming. Postpartum blood pressure can fluctuate, and this reading does not indicate a hypertensive crisis.

Choice D rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common postpartum due to fluid retention and is not typically a cause for immediate concern unless accompanied by other symptoms such as severe pain or redness.

Choice E rationale:

Soft breasts with intact nipples are normal findings in the early postpartum period, especially if the client is breastfeeding. There is no indication of issues such as mastitis or engorgement.

Choice F rationale:

A large amount of lochia rubra is concerning as it may indicate postpartum hemorrhage. Lochia should gradually decrease in amount and change in color over time. A large amount of bright red blood suggests excessive bleeding that requires immediate follow-up.

Choice G rationale:

A soft uterine tone is abnormal and can indicate uterine atony, which is a leading cause of postpartum hemorrhage. The uterus should be firm and contracted to prevent excessive bleeding.

Choice H rationale:

Lateral deviation of the uterus can indicate a full bladder, which can prevent the uterus from contracting properly and lead to increased bleeding. This requires immediate attention to ensure the bladder is emptied and the uterus can contract effectively.