Question

The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?

a) Lochia rubra with small clots
b) Uterus firm and at the level of the umbilicus
c) Blood pressure 120/80 mm Hg
d) Temperature 99.8°F (37.7°C)

Answer 1

A temperature of 99.8°F (37.7°C) 24 hours postpartum could suggest an infection and needs further evaluation. Lochia rubra, a firm uterus at the umbilical level, and a blood pressure of 120/80 mm Hg are normal postpartum findings.

Step-by-step explanation:

The nurse assesses a client who gave birth 24 hours earlier. Among the findings, a temperature of 99.8°F (37.7°C) could indicate the need for further evaluation. While a slight elevation in temperature can be normal due to the exertion of labor and dehydration, consistent or higher temperatures could signal an infection. The other options provided, including lochia rubra with small clots, a uterus that is firm and at the level of the umbilicus, and a blood pressure of 120/80 mm Hg, are within normal findings postpartum at 24 hours. Lochia rubra typically continues for 2-3 days before transitioning to lochia serosa and then to lochia alba over the next several weeks. The firmness and positioning of the uterus indicate that it is contracting normally as it undergoes involution. The blood pressure is within a healthy range for a postpartum woman.