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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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Long-acting reversible contraceptives, like an intrauterine device (IUD), are highly effective in preventing pregnancy. This statement is accurate and does not indicate a need for additional education.
Choice B rationale
Breastfeeding is not a form of contraception. This statement is correct as breastfeeding alone is not a reliable method of preventing pregnancy.
Choice C rationale
The statement “I will begin to use a barrier method after I start my first menstrual cycle” indicates a need for additional education. Ovulation can occur before the first postpartum menstrual cycle, so contraception should be used as soon as sexual activity resumes.
Choice D rationale
The withdrawal method is not very effective at avoiding pregnancy. This statement is accurate and does not indicate a need for additional education.
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale
A headache that is not relieved by hydration, rest, or over-the-counter medication can be a sign of postpartum preeclampsia, a serious condition that can occur after childbirth. Postpartum preeclampsia is characterized by high blood pressure and can lead to seizures, stroke, and other complications if not treated promptly.
Choice B rationale
Brownish red or pink lochia at 7 days postpartum is a normal finding. Lochia is the vaginal discharge that occurs after childbirth, and it typically changes color from bright red to pink or brownish red as the healing process progresses.
Choice C rationale
Chills and fever greater than 100.4°F (38.0°C) can indicate an infection, such as endometritis, which is an infection of the uterine lining. This condition requires prompt medical evaluation and treatment with antibiotics to prevent complications.
Choice D rationale
Feelings or thoughts of harming oneself or the infant are indicative of postpartum depression or postpartum psychosis, both of which are serious mental health conditions that require immediate attention and intervention from a healthcare provider.
Choice E rationale
Increased urinary output is a common postpartum finding as the body eliminates excess fluid retained during pregnancy. It is not typically a sign of a complication.
Choice F rationale
Redness, pain, or tenderness in the calf can be a sign of deep vein thrombosis (DVT), a blood clot that can occur in the legs. DVT is a serious condition that requires immediate medical evaluation and treatment to prevent the clot from traveling to the lungs and causing a pulmonary embolism.