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.
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Related Questions
Correct Answer is A
Explanation
A. Uterine atony is the most common cause of postpartum hemorrhage and is more likely to occur after a delivery of a large infant or in cases of rapid or prolonged labor.
B. Thrombophlebitis is a risk after childbirth, especially in clients who have undergone cesarean delivery or who have other risk factors such as prolonged immobility, but it is not directly related to the size of the newborn.
C. Puerperal infection is a risk following childbirth, but it is not directly related to the size of the newborn.
D. Retained placental fragments can lead to postpartum hemorrhage, but the size of the newborn is not a direct risk factor for this complication.
Correct Answer is B
Explanation
A. Keeping the baby's head elevated while feeding helps prevent choking and allows for easier swallowing.
B. Tipping the nipple to allow air during feeding is not recommended as it can lead to ingestion of air, causing discomfort and gas in the baby.
C. Allowing the baby to burp several times during each feeding helps release swallowed air, reducing the risk of colic and discomfort.
D. Soft, formed yellow stools are typical for a formula-fed newborn, indicating proper digestion.
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