A nurse is assisting with the care of a client who is 24 hours following a vaginal birth. Which of the following findings should the nurse report to the RN?

Postpartum assessment focuses on identifying normal involutional changes and detecting early signs of complications such as infection or hemorrhage. After a vaginal birth, the uterus should progressively contract, lochia should gradually decrease in volume and change color, and mild fluid shifts such as peripheral edema may occur. However, fever in the postpartum period is a significant abnormal finding that may indicate infection such as endometritis or urinary tract infection. Early recognition and reporting of abnormal vital signs are essential for preventing maternal complications. Rationale: A. A fundus located 2 cm below the level of the umbilicus 24 hours after delivery is an expected finding. The uterus typically descends approximately 1 cm per day as it involutes. This indicates normal uterine contraction and postpartum recovery. B. Scant lochia rubra 24 hours postpartum is a normal finding. Lochia rubra is expected in the first 1 to 3 days after birth and gradually decreases in amount. A scant amount suggests appropriate uterine healing and no evidence of excessive bleeding. C. Non-pitting bilateral peripheral edema can be a normal postpartum finding due to fluid shifts and increased intravascular volume during pregnancy. It typically resolves within a few days postpartum as the body excretes excess fluid. In the absence of other symptoms, it is not an immediate concern. D. An oral temperature of 38.8°C (101.8°F) is abnormal and should be reported immediately. Fever in the postpartum period may indicate infection such as endometritis, mastitis, or urinary tract infection. Early intervention is necessary to prevent progression to systemic infection or sepsis.