A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Orthostatic hypotension
Urine output of 3,000 mL in 12 hr
Heart rate 160/min
Fundus palpable at the umbilicus
The Correct Answer is C
Choice A reason: Orthostatic hypotension is a normal finding in the postpartum period, because the client has a sudden decrease in blood volume after delivery. The nurse should instruct the client to change positions slowly and drink plenty of fluids.
Choice B reason: Urine output of 3,000 mL in 12 hr is a normal finding in the postpartum period, because the client has increased renal perfusion and diuresis after delivery. The nurse should encourage the client to empty the bladder frequently and monitor the intake and output.
Choice C reason: Heart rate 160/min is an abnormal finding in the postpartum period, because it indicates tachycardia, which can be a sign of infection, dehydration, hemorrhage, or cardiac complications. The nurse should assess the client's temperature, blood pressure, pulse, respirations, skin color, lochia, and pain level, and report any abnormal findings to the provider.
Choice D reason: Fundus palpable at the umbilicus is a normal finding in the postpartum period, because the uterus gradually involutes and descends into the pelvis after delivery. The nurse should palpate the fundus and check for firmness, position, and height. The fundus should be at the level of the umbilicus immediately after delivery, and descend about one fingerbreadth per day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Missed miscarriage is not the type of abortion that the client is experiencing, because it is characterized by the absence of fetal heart activity and the retention of the products of conception in the uterus. The client would not have heavy bleeding or tissue expulsion.
Choice B reason: Incomplete miscarriage is the type of abortion that the client is experiencing, because it is characterized by the partial expulsion of the products of conception from the uterus, with some tissue remaining inside. The client would have heavy bleeding, open cervical os, and tissue present.
Choice C reason: Inevitable miscarriage is not the type of abortion that the client is experiencing, because it is characterized by the rupture of membranes and dilation of the cervical os, but no expulsion of the products of conception. The client would have moderate bleeding and cramping, but no tissue present.
Choice D reason: Complete miscarriage is not the type of abortion that the client is experiencing, because it is characterized by the complete expulsion of the products of conception from the uterus. The client would have mild bleeding and cramping, and a closed cervical os.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as it is not helpful to use euphemisms or avoid the words dead or died when talking about the loss of an infant. Using the words lost or gone can imply that the baby is not really dead, or that the baby can be found or returned, which can create confusion and denial in the family. Using the words dead or died can help the family to acknowledge and accept the reality of the loss, and to express their grief and emotions.
Choice B reason: This statement is incorrect, as it is not helpful to set a firm time for ending the visit with the baby, as it can make the parents feel rushed, pressured, or controlled. Setting a firm time for ending the visit can interfere with the parents' natural process of saying goodbye to the baby, and can prevent them from creating memories and bonding with the baby. The parents should be allowed to decide how long they want to spend with the baby, and to end the visit when they are ready.
Choice C reason: This statement is incorrect, as it is not helpful to encourage the family not to give the baby a name, as it can make the baby seem less real, less important, or less valued. Encouraging the family not to give the baby a name can deny the family's right to recognize and honor the baby as a person, and to establish a relationship and an identity with the baby. The family should be supported to give the baby a name, and to use the name when referring to the baby.
Choice D reason: This statement is correct, as it is helpful to ensure the baby is clothed or wrapped if the parents choose to visit with the baby, as it can make the baby look more comfortable, warm, and human. Ensuring the baby is clothed or wrapped can facilitate the parents' physical contact and interaction with the baby, and can enhance the parents' perception and memory of the baby. The parents should be offered to choose the clothing or the blanket for the baby, and to keep them as mementos.
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