# The nurse reviews the client's electronic health record. Which findings require immediate follow-up? Highlight the findings in the nurses' notes. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=556763&lang=en > language: en > subject: Lifestyle Choices > category: HPM ## Question The nurse reviews the client's electronic health record. Which findings require immediate follow-up? Highlight the findings in the nurses' notes. Nurses' Notes 0915: The client is 8 days postpartum following a cesarean birth and calls the obstetric clinic. She was discharged on postoperative day 3 after an uncomplicated recovery. The client reports a headache that began yesterday and has not improved after acetaminophen and fluids. She states, "I see flashing spots when I stand and walk across the room." She reports sleeping in 2-hour blocks while feeding the newborn. The client states that both ankles are mildly swollen by evening and improve when elevated. She reports pink-brown lochia that is lighter than at hospital discharge. The client reports new pain under the right ribs with intermittent nausea. She states that her breasts feel full before feeding and soften after the newborn nurses. During the call, the nurse notes that the client becomes short of breath while speaking and pauses to finish a sentence. The client reports incisional discomfort rated 3/10 with turning that improves at rest. She reports one soft bowel movement this morning after taking the prescribed stool softener. The client states that her oral temperature is 37.4 °C (99.3 °F). The incision is dry with the edges approximated. She denies unilateral calf pain, and her partner is available to drive. ## Explanation Persistent headache with visual changes, right-upper-quadrant pain, and breathlessness after birth are urgent maternal warning signs. When neurologic, hepatic, or breathing cues cluster postpartum, escalate now rather than offering routine home-care advice. ## In-depth explanation Quick answer The urgent cues are the persistent headache, flashing visual spots, right-upper-quadrant pain with nausea, and shortness of breath while speaking. Together they can signal a serious postpartum hypertensive or cardiopulmonary complication and require prompt in-person assessment. Why this is correct Postpartum preeclampsia can appear after a pregnancy with previously normal blood pressure. A headache that does not improve, visual disturbance, and upper-abdominal pain are recognized warning signs; difficulty breathing is also an urgent maternal warning sign.[1][2] The nurse should not let the normal-looking incision or improving lochia dilute the importance of these new symptoms. Easy analogy or mental picture Think of a dashboard showing several red warning lights at once. Each light maps to a body system—headache and vision to neurologic involvement, right-upper-quadrant pain to possible hepatic involvement, and breathlessness to cardiopulmonary stress. The analogy stops there: warning lights do not diagnose the cause, so the client still needs an actual assessment. Memory hook Head + sight + right-side pain + breath = do not manage only by phone. Use the pattern as an escalation checklist, not as a diagnosis. NCLEX decision rule When a recently pregnant client has a persistent neurologic symptom, upper-abdominal pain, or trouble breathing, think urgent maternal complication; check current stability and arrange immediate evaluation before giving routine comfort advice. Why the other choices are wrong Improving pink-brown lochia, breast fullness that softens after feeding, mild dependent ankle swelling that improves with elevation, positional incisional discomfort, and a low-grade temperature can occur during uncomplicated recovery. They remain worth monitoring, but they do not outweigh the new multisystem warning signs in this note.References - [1]ACOG: 3 Conditions to Watch for After ChildbirthAmerican College of Obstetricians and Gynecologists - [2]ACOG: Urgent Maternal Warning SignsAmerican College of Obstetricians and Gynecologists - [3]2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing ## Related questions - [A client who smokes says, “I know smoking worsens my breathing, and part of me wants to qu…](https://mymerci.kr/pages/nclex_q.php?qn_id=393389&lang=en) - [A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The …](https://mymerci.kr/pages/nclex_q.php?qn_id=394059&lang=en) - [The nurse teaches parents of a 3-day-old newborn about jaundice. Which finding should the …](https://mymerci.kr/pages/nclex_q.php?qn_id=394157&lang=en) - [Drag each adult-vaccination scenario to the most appropriate planning category.](https://mymerci.kr/pages/nclex_q.php?qn_id=395453&lang=en) - [An unsensitized Rh-negative client at 30 weeks of pregnancy is evaluated after a minor mot…](https://mymerci.kr/pages/nclex_q.php?qn_id=397171&lang=en) - [A breastfeeding client has mastitis and asks whether to stop feeding from the affected bre…](https://mymerci.kr/pages/nclex_q.php?qn_id=397342&lang=en) - [The nurse reviews infant-care teaching with a parent. Which statements require follow-up? …](https://mymerci.kr/pages/nclex_q.php?qn_id=494270&lang=en) - [The public health nurse reviews osteoporosis screening plans. Which plans require follow-u…](https://mymerci.kr/pages/nclex_q.php?qn_id=495005&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=556763&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=556763&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=556763&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=556763&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=556763&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._