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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?

A.

Heart rate 125 bpm.

B.

Fundus palpable at the umbilicus.

C.

Urine output of 3,000 mL in 24 hr.

D.

Orthostatic hypotension.

Answer and Explanation

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 D

Explanation

Choice A rationale

Changing the dressing on a cesarean incision for a patient who is 1 day post-op requires sterile technique and assessment skills, which are beyond the scope of practice for assistive personnel (AP). This task should be performed by a licensed nurse.

Choice B rationale

Documenting the lochia amount on the perineal pad of a client who just transferred from labor and delivery involves assessment and documentation, which are nursing responsibilities. This task should not be delegated to AP.

Choice C rationale

Assessing an area of redness on the breast of a client who is 4 days postpartum requires clinical judgment and assessment skills, which are within the scope of practice for a licensed nurse. This task should not be delegated to AP.

Choice D rationale

Providing a sitz bath to a client who has a third-degree laceration and is 2 days postpartum is an appropriate task for AP. It is a comfort measure that does not require clinical judgment or assessment skills, making it suitable for delegation to AP.

Correct Answer is D

Explanation

Choice A rationale

Pumping out the milk when breasts become engorged can provide temporary relief, but it can also stimulate further milk production, leading to continued engorgement. This is not recommended for clients who are not planning to breastfeed.

Choice B rationale

Not wearing a bra throughout the day can lead to discomfort and inadequate support for engorged breasts. Wearing a supportive bra, such as a sports bra, can help alleviate discomfort and provide necessary support.

Choice C rationale

Applying hot packs to the breasts can increase blood flow and exacerbate engorgement. Cold packs or ice packs are recommended to reduce swelling and provide relief from discomfort.

Choice D rationale

Avoiding stimulation to the nipples is an effective measure to reduce milk production and alleviate breast engorgement. This includes avoiding activities that may stimulate the nipples, such as pumping or hand expressing milk.

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