A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Urine output of 3,000 mL in 12 hours

Fundus palpable at the umbilicus

Orthostatic hypotension

Heart rate 110/min

Answer and Explanation

The Correct Answer is D

A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.

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Correct Answer is B

Explanation

A. Covering the cord with the diaper can increase moisture around the stump, leading to delayed cord separation and potential infection.
B. Giving a sponge bath until the cord stump falls off helps to keep the area clean and dry, reducing the risk of infection.
C. Washing the cord daily with mild soap and water is not recommended as it can increase the risk of infection and delay cord separation.
D. Applying petroleum jelly to the cord stump is not recommended as it can trap moisture and increase the risk of infection.

A. Preeclampsia B. Disseminated intravascular coagulation C. Puerperal infection D. Anaphylactoid syndrome of pregnancy

Correct Answer is B

Explanation

A. Petechiae and bleeding around the IV access site are not typically associated with preeclampsia.
B. Disseminated intravascular coagulation (DIC) is a potential complication of abruptio placentae, characterized by widespread activation of the clotting cascade followed by consumption of clotting factors, leading to bleeding and microvascular thrombosis.

C. Puerperal infection is a risk following childbirth but is not specifically associated with petechiae and bleeding around the IV access site.
D. Anaphylactoid syndrome of pregnancy is a rare complication characterized by sudden hypotension, bronchospasm, and vascular collapse, which is not typically associated with petechiae and bleeding around the IV access site.

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A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Correct Answer is B

Explanation

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