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 D
Explanation
A. Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
Correct Answer is A
Explanation
A. The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.
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