The Nurse Is Caring for a Client in the Fourth

Multiple Choice

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.)

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