A nurse is collecting data from a postpartum client.
Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Fundus at umbilicus level

Urinary output 3,000 mL

Temperature 100.4 F for two days

Cesarean section shortly following delivery

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus

(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and

descend into the pelvic cavity, guided by the process known as involution.

Choice B rationale:

A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common

as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of

postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized

by high blood pressure and signs of damage to another organ system, often the kidneys.

Choice C rationale:

A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a

slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above 100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.

Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.

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Correct Answer is C

Explanation

Choice C rationale:

Monitoring contraction frequency is essential to assess the progression of labor. Contractions are the tightening and relaxing of the uterine muscles that help to dilate the cervix and push the baby down the birth canal. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next. As labor progresses, contractions become more frequent, regular, and intense. Monitoring contraction frequency helps the nurse to determine the stage of labor, assess the effectiveness of interventions, and identify any potential complications.

Monitoring fetal heart rate is crucial to assess the well-being of the baby during labor. The fetal heart rate is normally between 110 and 160 beats per minute. A normal fetal heart rate indicates that the baby is getting enough oxygen and is not in distress. Variations in the fetal heart rate, such as decelerations or tachycardia, can indicate potential problems and may require intervention.

Choice A rationale:

Preterm labor is defined as labor that begins before 37 weeks of gestation. The client in this scenario is at 38 weeks of gestation, which is considered term. Therefore, preterm labor is not the most likely condition.

Choice B rationale:

The administration of medication and bed rest may be appropriate interventions for preterm labor, but they are not the most appropriate interventions for a client in labor at 38 weeks of gestation. At this stage of pregnancy, labor is considered to be full-term, and interventions are focused on supporting the normal labor process and ensuring the safety of the mother and baby.

A. I will stop breastfeeding until I am done with the antibiotics B. Apply cold compresses 20 min before each feeding C. Feed my baby every 2 hours D. I won't wear a bra during the daytime

Correct Answer is C

Explanation

Choice A rationale:

Stopping breastfeeding until the antibiotics are done is not a recommended practice. Most antibiotics are safe to use while

breastfeeding. Moreover, stopping breastfeeding can lead to engorgement.

Choice B rationale:

Applying cold compresses 20 minutes before each feeding is not a recommended practice. Cold compresses are usually

recommended after breastfeeding to help reduce swelling. Warm compresses or taking a warm shower before breastfeeding

can help increase milk flow and promote the letdown reflex.

Choice C rationale:

Feeding the baby every 2 hours is a good practice to prevent breast engorgement. Frequent feeding helps to empty the breasts,

which can prevent them from becoming overly full and engorged.

Choice D rationale:

Not wearing a bra during the daytime is not a recommended practice. Wearing a well-fitted bra can provide support and help

reduce discomfort associated with breast engorgement.

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A nurse is collecting data from a postpartum client. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is at 38 weeks of gestation. What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

Correct Answer is C

Explanation

Choice C rationale:

Choice A rationale:

Choice B rationale:

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn.Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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A nurse is collecting data from a postpartum client.
Which of the following findings should alert the nurse to the possibility of a postpartum complication?