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
An intrauterine device (IUD) is one of the most reliable methods of contraception. It is a small, T-shaped device inserted into the uterus by a healthcare provider. IUDs can be hormonal or non-hormonal (copper). Hormonal IUDs release progestin, which thickens cervical mucus to prevent sperm from reaching the egg and thins the uterine lining to prevent implantation. Copper IUDs release copper ions, which are toxic to sperm. Both types of IUDs are over 99% effective and can last for several years, making them a highly reliable form of contraception.
Choice B rationale
Oral contraceptives, commonly known as birth control pills, are also effective but require daily adherence. They contain hormones (estrogen and progestin) that prevent ovulation, thicken cervical mucus, and thin the uterine lining. However, their effectiveness can decrease with missed doses, certain medications, or gastrointestinal disturbances. With typical use, their effectiveness is around 91%, meaning 9 out of 100 women may become pregnant each year.
Choice C rationale
Male condoms are a barrier method of contraception that prevent sperm from entering the uterus. They are also effective in preventing sexually transmitted infections (STIs). However, their effectiveness can be compromised by improper use, breakage, or slippage. With typical use, male condoms are about 85% effective, meaning 15 out of 100 women may become pregnant each year.
Choice D rationale
A diaphragm with spermicide is a barrier method of contraception. The diaphragm is a shallow, dome-shaped cup inserted into the vagina to cover the cervix, and spermicide is applied to kill sperm. Its effectiveness depends on correct and consistent use. With typical use, diaphragms are about 88% effective, meaning 12 out of 100 women may become pregnant each year. Additionally, diaphragms do not protect against STIs.
Correct Answer is D
Explanation
Choice A rationale
Swelling in both breasts is more indicative of engorgement rather than mastitis. Mastitis typically affects only one breast.
Choice B rationale
A white patch on a nipple is more likely a sign of a yeast infection (thrush) rather than mastitis.
Choice C rationale
Cracked and bleeding nipples can be a risk factor for mastitis but are not a definitive sign of the condition.
Choice D rationale
A red and painful area in one breast is a classic sign of mastitis. This condition is often accompanied by flu-like symptoms such as fever and malaise.