A nurse is assisting in the care of a client on a postpartum unit. The client had an uncomplicated vaginal delivery 24 hours ago. Which of the following data collection findings should the nurse report to the primary RN immediately?
Explanation & Rationale
A. Moderate lochia rubra on the pad: Moderate lochia 24 hours postpartum is considered a normal finding as the uterus continues to shed the lining. It typically appears bright red and gradually decreases over the following days, so it does not require immediate reporting. B. Nipple tenderness with breastfeeding: Nipple tenderness is common in the early postpartum period due to breastfeeding, especially if the latch is not optimal. While it should be addressed to prevent complications, it is not an urgent finding requiring immediate reporting. C. Hemorrhoids on the rectal area: Hemorrhoids are a frequent postpartum occurrence, often resulting from vaginal delivery or straining during labor. They are uncomfortable but not emergent, so they do not need immediate reporting. D. Calf edematous and tender: A calf that is swollen, edematous, and tender may indicate a deep vein thrombosis (DVT), which is a potentially life-threatening postpartum complication. This finding requires immediate reporting to the primary RN for timely assessment and intervention.