Question

A nurse is caring for a postpartum client.

A nurse is performing an assessment on the client. Which of the following findings should the nurse report to the provider?
Select all that apply.

History and Physical
Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago
42 years old
Gravida 2, Para 1
History of hypertension
History of asthma
No antihypertensive medications during pregnancy.
Treatment plan included diet and exercise.

Nurses' Notes
1730:
Client is awake and alert.
Fundus is firm, midline, and 2 cm below the umbilicus.
Incision is intact, light amount of lochia rubra observed.
+2 pitting edema observed to bilateral lower extremities.
Reports headache pain as 3 on a scale of 0 to 10.
Reports headache and heartburn began about 1 hr ago.

Vital Signs
1730:
Blood pressure 152/105 mm Hg, Temperature 37.8° C (100° F), Pulse 70/min, Respiratory rate 20/min, Oxygen saturation 98%

Diagnostic Results
Admission laboratory values (48 hr ago):
Hgb 11 g/dL (greater than 11 g/dL)
Platelets 150,000/mm³ (150,000 to 400,000/mm³)
BUN 19 mg/dL (10 to 20 mg/dL)
Creatinine 1 mg/dL (0.5 to 1 mg/dL)
Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L)
Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L)

Urinalysis:
Color: pink-tinged
pH 6.2 mg/dL (4.6 to 8 mg/dL)
Specific gravity 1.022 (1.010 to 1.025)
Leukocyte esterase Negative (Negative)
Nitrite negative (Negative)
Protein 0 mg/dL (0 to 8 mg/dL)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Red blood cells: >20 (≤2)


A. Fundus 2 cm below the umbilicus
B. Blood pressure 152/105 mm Hg
C. +2 pitting edema
D. Headache
E. Heartburn
F. Light amount of lochia rubra

Answer 1

The nurse should report the elevated blood pressure, +2 pitting edema, headache, and heartburn to the healthcare provider as these findings may indicate postpartum hypertension or other complications requiring immediate medical attention.

Step-by-step explanation:

A nurse performing an assessment on a postpartum client should report certain findings to the healthcare provider. In this scenario, the findings that should be reported include the client's blood pressure of 152/105 mm Hg, the presence of +2 pitting edema to bilateral lower extremities, the complaint of a headache rated 3 on a scale from 0 to 10, and heartburn that began about 1 hour ago.

The other observations such as the fundus being firm and midline 2 cm below the umbilicus and the light amount of lochia rubra are normal postpartum findings within 48 hours after a cesarean delivery. However, the elevated blood pressure may indicate postpartum hypertension, the edema could suggest fluid retention or preeclampsia, and the new onset of headache and heartburn could be symptoms of a more serious condition and warrant further evaluation by a healthcare provider.