A nurse is reinforcing discharge teaching with a client who is pregnant and was treated for a urinary tract infection. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

A. A client whose newborn is having difficulty latching-on should be addressed, but this issue is not an immediate postpartum emergency. It is important but does not require urgent intervention compared to potential complications from magnesium sulfate.
B. A client who received magnesium sulfate during labor should be seen first because magnesium sulfate can cause significant side effects like respiratory depression, decreased reflexes, and altered mental status. These effects require close monitoring to prevent severe complications.
C. A client who has a history of oligohydramnios requires monitoring but this history does not necessarily indicate an immediate postpartum issue requiring urgent assessment at this time.
D. A client whose labor lasted for 6 hr does not have an immediate concern solely based on labor duration. While it is relevant, it does not indicate an urgent need for assessment compared to the effects of magnesium sulfate.

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.