A nurse is caring for a client who is 18 hours postpartum. Which finding should alert the nurse to the possibility of a postpartum complication?
Heart rate 125 bpm.
Fundus palpable at the umbilicus.
Urine output of 3,000 mL in 24 hr.
Orthostatic hypotension.
The Correct Answer is A
Choice A rationale
A heart rate of 125 bpm is significantly elevated and may indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia in the postpartum period warrants further assessment and intervention to identify and address the cause.
Choice B rationale
The fundus being palpable at the umbilicus is normal for 18 hours postpartum. The uterus gradually descends into the pelvis over the postpartum period, and its position at the umbilicus at this stage is expected.
Choice C rationale
A urine output of 3,000 mL in 24 hours is within the normal range for postpartum diuresis. Increased urine output is common as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
Orthostatic hypotension can occur in the postpartum period due to blood volume changes and fluid shifts. While it requires monitoring, it is not as immediately concerning as tachycardia, which may indicate a more serious complication.
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Correct Answer is A
Explanation
Choice A rationale
The client is exhibiting expected assessment findings. Three days postpartum, it is normal for the fundus to be three fingerbreadths below the umbilicus, lochia rubra to be light, and the breasts to be full and warm to palpation without evidence of redness or pain. These findings indicate that the uterus is involuting properly, and the breasts are producing milk for breastfeeding.
Choice B rationale
The client is not exhibiting indications of mastitis. Mastitis is characterized by breast tenderness, redness, warmth, and pain, often accompanied by fever and flu-like symptoms. The absence of these symptoms suggests that the client does not have mastitis.
Choice C rationale
There is no indication that the client should be advised to remove her nursing bra. A well-fitting nursing bra can provide support and comfort during breastfeeding. The client should continue to wear a nursing bra as needed.
Choice D rationale
There is no indication that the client should be advised to stop breastfeeding. The assessment findings suggest that breastfeeding is going well, and the client should be encouraged to continue breastfeeding to provide optimal nutrition for the infant.
Correct Answer is B
Explanation
Choice A rationale
A 29-year-old G3P3003 with an uncomplicated SVD at term and a supportive family environment is less likely to experience difficulties in transitioning to motherhood. The presence of her husband and older daughter provides a strong support system, which is beneficial for her adjustment.
Choice B rationale
A 37-year-old G3P1112 with worsening preeclampsia, induced at 34 weeks, currently on Magnesium Sulfate, and with a baby in the NICU, faces multiple stressors. The medical complications, preterm delivery, and separation from her baby due to NICU admission increase her risk for a difficult transition to motherhood. The use of Magnesium Sulfate can also affect her physical and emotional well-being.
Choice C rationale
A 31-year-old G3P2012 with a history of depression and a husband who is deployed faces significant challenges. The history of depression increases her risk for postpartum depression, and the absence of her husband can lead to feelings of isolation and increased stress.
Choice D rationale
A 16-year-old G1P1001 who delivered via cesarean section is at risk due to her young age and the surgical delivery. Adolescents may have less experience and resources to cope with the demands of motherhood, and the recovery from a cesarean section can add to the physical and emotional challenges.
Choice E rationale
A 20-year-old G1P1001 with an uncomplicated SVD and the presence of her boyfriend is less likely to face significant difficulties. The uncomplicated delivery and the support of her boyfriend provide a stable environment for her transition to motherhood. .