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. Pain following a cesarean birth is important to address, but it may not indicate an urgent need for assessment compared to other potential complications.
B. A client with preeclampsia requires close monitoring of blood pressure to prevent

complications such as eclampsia, which can lead to seizures and other serious consequences. An elevated blood pressure reading warrants immediate attention.
C. A client scheduled for discharge following a laparoscopic tubal ligation is stable and can likely wait for assessment until after higher-priority clients have been seen.
D. While it's important to monitor for bleeding after a vaginal birth, the absence of bleeding reported by a client 24 hours postpartum may not indicate an immediate need for assessment compared to the potential urgency of managing preeclampsia.

A. "I'll feed my baby every 2 hours." B. "I'll apply cold compresses 20 minutes before each feeding." C. "I'll try drinking an herbal tea to reduce the engorgement." D. "I'll let my baby drain one breast at each feeding."

Correct Answer is A

Explanation

Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.

Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.

Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.

Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.

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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?

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Naxlex Comprehensive Predictor Exams

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