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
Galactopoiesis is the process of lactation maintenance and is reliant on breast stimulation and milk removal. This stage involves the ongoing production of milk in response to the infant’s demand.
Choice B rationale
Lactogenesis II refers to the onset of copious milk secretion that occurs around 2-3 days postpartum. It is triggered by the withdrawal of progesterone following the delivery of the placenta.
Choice C rationale
Mammogenesis is the development of the mammary glands during pregnancy. It involves the growth and differentiation of the breast tissue in preparation for lactation.
Choice D rationale
Lactogenesis I refers to the initial stage of milk production that begins during pregnancy and continues through the early postpartum period. It is hormonally driven and prepares the breasts for lactation. .
Correct Answer is A
Explanation
Choice A rationale
Asking the client if she has thoughts of or considered harming herself or her newborn is the priority action. This assessment is crucial for identifying postpartum depression and potential risks to the client and her newborn. Early identification and intervention can prevent harm.
Choice B rationale
Anticipating a prescription for an antidepressant is important but secondary to assessing immediate safety concerns. Medication can be part of the treatment plan after assessing the client’s mental state.
Choice C rationale
Assisting the family to identify prior use of positive coping skills is beneficial for long-term management but is not the immediate priority. The nurse must first ensure the client’s and newborn’s safety.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important for overall care but does not address the immediate concern of potential harm due to postpartum depression.