A nurse is collecting data from a postpartum client.
Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Choice A rationale:

The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus

(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and

descend into the pelvic cavity, guided by the process known as involution.

Choice B rationale:

A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common

as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of

postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized

by high blood pressure and signs of damage to another organ system, often the kidneys.

Choice C rationale:

A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a

slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.

Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.

Choice A rationale:

Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by

placing pressure on the perineum and reducing blood flow to the area.

Additionally, it can separate the buttocks, further straining the incision site and hindering healing.

It's crucial to prioritize interventions that promote circulation and reduce pressure on the perineum to facilitate healing and

pain management.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery.

Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying

healing.

It's essential to allow the initial inflammatory phase of wound healing to subside before introducing heat therapy.

Choice D rationale:

Preparing a warm sitz bath is a helpful intervention for episiotomy pain, but it's generally recommended after the first 24

hours.

During the initial phase of healing, warm water can increase blood flow to the area, potentially leading to increased swelling

and discomfort.

It's often more beneficial to focus on cooling measures within the first 24 hours to reduce inflammation and promote comfort.

Choice B rationale:

Applying an ice pack to the perineum is the most appropriate action for the nurse to take in this scenario.

Cold therapy effectively reduces inflammation, swelling, and pain by constricting blood vessels and slowing nerve conduction.

It's a non-invasive and readily available intervention that can significantly improve comfort and promote healing in the early

stages of episiotomy recovery.

Key points:

Ice packs are generally recommended for the first 24 hours following an episiotomy to reduce pain and inflammation.

Heat therapy, such as sitz baths or heating lamps, can be helpful after the initial 24-hour period to promote circulation and

healing.

Pillows or cushions under the buttocks should be avoided as they can increase pressure on the perineum and worsen pain.

Nurses play a crucial role in educating clients about episiotomy care and providing appropriate pain relief measures.