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 C
Explanation
Choice A rationale
A high-fat diet is not recommended for breastfeeding mothers. While fats are an essential part of a balanced diet, excessive intake of high-fat foods can lead to unhealthy weight gain and may not provide the necessary nutrients for both the mother and the baby. Breastfeeding mothers should focus on a balanced diet that includes healthy fats, proteins, and carbohydrates to support their nutritional needs and milk production.
Choice B rationale
Stopping prenatal vitamins is not advisable for breastfeeding mothers. Prenatal vitamins contain essential nutrients such as folic acid, iron, and calcium that support the health of both the mother and the baby. Continuing to take prenatal vitamins can help ensure that breastfeeding mothers receive adequate nutrients, especially if their diet may not provide all the necessary vitamins and minerals.
Choice C rationale
Breastfeeding mothers need an additional 450-500 kCal per day to meet their increased energy requirements. This extra caloric intake supports milk production and helps the mother maintain her energy levels. The additional calories should come from a balanced diet that includes a variety of nutrient-dense foods.
Choice D rationale
Consuming only 8-16 oz of water per day is insufficient for breastfeeding mothers. Adequate hydration is crucial for milk production and overall health. Breastfeeding mothers should aim to drink at least 8-10 cups (64-80 oz) of water per day to stay hydrated and support their body’s increased fluid needs.