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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encouraging the client to move to the left lateral position helps to promote uterine
contractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.
Correct Answer is C
Explanation
A. Monitoring weight is important for assessing growth but may not be the priority for a
newborn who is small for gestational age (SGA) as it doesn't address immediate physiological needs.
B. Monitoring axillary temperature is important for detecting signs of infection or hypothermia, but it's not the priority for a newborn who is small for gestational age (SGA).
C. Monitoring blood glucose levels is the priority for a newborn who is small for gestational age (SGA) because they are at risk for hypoglycemia due to inadequate glycogen stores.
D. Monitoring intake and output is important for overall assessment but is not the priority intervention for a newborn who is small for gestational age (SGA).
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