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?
Explanation & Rationale
A. Fundus is located 2 cm (0.4 in) below the level of the umbilicus: A fundus slightly below the umbilicus 24 hours postpartum is expected as the uterus involutes. This is a normal finding and does not require immediate reporting unless accompanied by excessive bleeding or other concerning signs. B. Scant lochia rubra on the perineal pad: Scant lochia rubra is typical within the first 24 hours postpartum, indicating normal uterine shedding. It is expected and does not indicate a complication in the absence of heavy bleeding or foul odor. C. Non-pitting bilateral peripheral edema: Mild non-pitting edema in the lower extremities can occur postpartum due to fluid shifts and is usually self-limiting. It is not typically emergent unless accompanied by severe swelling, pain, or signs of deep vein thrombosis. D. Oral temperature of 38.8° C (101° F): An elevated temperature above 38° C 24 hours postpartum may indicate infection, such as endometritis or urinary tract infection. This finding requires immediate reporting to the RN for further assessment and intervention.