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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Uterine enlargement greater than expected for gestational age is not a typical manifestation of ectopic pregnancy, because the embryo is implanted outside the uterus, usually in the fallopian tube. The uterus may be slightly enlarged due to hormonal changes, but not more than expected for the gestational age.
Choice B reason: Unilateral, cramp-like abdominal pain is a common manifestation of ectopic pregnancy, because the embryo grows and stretches the fallopian tube, causing inflammation and irritation. The pain may be mild or severe, depending on the size and location of the ectopic pregnancy, and may radiate to the shoulder or back.
Choice C reason: Severe nausea and vomiting is not a specific manifestation of ectopic pregnancy, because it can be caused by other conditions, such as hyperemesis gravidarum, gastroenteritis, or appendicitis. The client may have mild nausea and vomiting due to hormonal changes, but not more than usual for the gestational age.
Choice D reason: Large amount of vaginal bleeding is not a usual manifestation of ectopic pregnancy, because the bleeding is usually internal, into the abdominal cavity. The client may have spotting or light bleeding due to the detachment of the endometrium, but not heavy or profuse bleeding.
Correct Answer is B
Explanation
Choice A reason: Increased risk of anemia is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn regardless of the maternal diabetes status or the fetal size. Anemia can cause pallor, tachycardia, and poor feeding, but not respiratory distress.
Choice B reason: Hyperinsulinemia is a likely cause of respiratory distress in a term macrosomic newborn, as it results from the fetal exposure to high maternal glucose levels and the subsequent overproduction of insulin. Hyperinsulinemia can impair the synthesis of surfactant, which is a substance that prevents the alveoli from collapsing and facilitates gas exchange. Hyperinsulinemia can also cause hypoglycemia, which can affect the respiratory center and cause apnea.
Choice C reason: Increased blood viscosity is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn with polycythemia, which is an abnormally high number of red blood cells. Polycythemia can cause cyanosis, jaundice, and thrombosis, but not respiratory distress.
Choice D reason: Brachial plexus injury is not a likely cause of respiratory distress in a term macrosomic newborn, as it affects the nerves that supply the arm and hand, not the lungs. Brachial plexus injury can occur due to the excessive traction or stretching of the shoulder during delivery, and can cause weakness, paralysis, or sensory loss in the affected arm.
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