Exhibits The nurse reviews the nurse's notes and flow chart to identify trends. Click to specify the notations that require immediate follow up (more than one notation may be correct.) Body System Circulatory Heart rate 96 beats/minute Blood pressure 90/62 mm Hg IV infusing at 125 ml/hr Respirations 16 breaths/minute Respiratory Oxygen saturation of 89% Several deep breaths Integumentary Episiotomy intact with no redness Pad is saturated with blood 18 gauge IV to left forearm Genital/Urinary Boggy fundus 1 cm above umbilicus Fundus rotated to the right Voided 200 mL of clear yellow urine

Blood pressure 90/62 mm Hg A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications. Oxygen saturation of 89% An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions. Fundus rotated to the right The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.