Question

question: 38 of 85
a nurse is caring for a client who is 2 days postpartum. which of the following findings should the nurse report to the provider?
scant lochia rubra with a few small clots
bilateral ankle edema
4+ deep - tendon reflexes
urine output 2,500 ml/day

Explanation:

• Scant lochia rubra with a few small clots: This is a normal finding in the early postpartum period (lochia rubra is normal for about 3 - 4 days postpartum, and small clots can be present).
• Bilateral ankle edema: Mild bilateral ankle edema can be normal in the postpartum period due to fluid shifts.
• 4+ deep - tendon reflexes: Deep - tendon reflexes (DTRs) are typically graded on a scale. A grade of 4+ indicates hyperreflexia. In the postpartum period, especially if a client had pre - eclampsia (a condition associated with hyperreflexia), hyperreflexia (4+ DTRs) is an abnormal finding that should be reported as it can be a sign of ongoing neurological or hypertensive issues.
• Urine output 2,500 mL/day: Increased urine output (diuresis) is normal in the postpartum period as the body rids itself of the excess fluid from pregnancy.

Answer:

4+ deep - tendon reflexes