The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

Question

a. Soft boggy uterus
b. Maternal temperature of 99° F
c. High uterine fundus displaced to the right
d. Intense vaginal pain unrelieved by analgesics
e. Half of a lochia pad saturated in the first hour after birth

Answer 1

ANS: A, C, D
Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.