A nurse is caring for a postpartum client, 2 days after birth. Which of the following expected findings does the nurse associate with the cardiovascular system changes in the postpartum period?
Temperature 99.0°F (37.3°C).
Respiratory rate of 18/min.
WBC 22,000/mm³.
Urinary retention.
The Correct Answer is C
Choice A rationale
A temperature of 99.0°F (37.3°C) is within the normal range and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice B rationale
A respiratory rate of 18/min is within the normal range for adults and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice C rationale
An elevated white blood cell (WBC) count of 22,000/mm³ is a common finding in the postpartum period due to the body’s response to the stress of childbirth. This leukocytosis is a normal physiological response and is associated with the cardiovascular system changes during this period.
Choice D rationale
Urinary retention is not specifically associated with cardiovascular system changes in the postpartum period. It can occur due to various reasons, including the effects of anesthesia or trauma during delivery, but it is not a direct result of cardiovascular changes.
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Correct Answer is C
Explanation
Choice A rationale
Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It is more common in breastfeeding women and typically occurs when bacteria enter the breast tissue through a cracked or sore nipple. While it is a postpartum complication, it is not specifically associated with the delivery of twins.
Choice B rationale
Uterine infection, also known as endometritis, is an infection of the uterine lining. It can occur after childbirth, especially if there were complications such as prolonged labor, multiple vaginal exams, or manual removal of the placenta. However, it is not specifically associated with the delivery of twins.
Choice C rationale
Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. The risk of uterine atony is higher in cases of overdistension of the uterus, such as with multiple gestations (twins), polyhydramnios, or a large baby. Therefore, a client who has delivered twins is at increased risk for uterine atony.
Choice D rationale
Retained placental fragments occur when parts of the placenta remain in the uterus after childbirth. This can lead to postpartum hemorrhage and infection. While it is a potential complication, it is not specifically associated with the delivery of twins.
Correct Answer is C
Explanation
Choice A rationale
Encouraging the client to empty her bladder is a common practice to prevent uterine atony and excessive bleeding. However, in this scenario, the fundus is already midline and firm at the umbilicus, indicating that the uterus is well-contracted. Therefore, this action is not necessary.
Choice B rationale
Notifying the client’s provider is not required in this situation. The findings of a light amount of lochia rubra and a firm, midline fundus are normal for 6 hours postpartum. There are no signs of complications that would necessitate contacting the provider.
Choice C rationale
Documenting the findings and continuing to monitor the client is the appropriate action. The client’s condition is stable, and the findings are within the expected range for 6 hours postpartum. Ongoing monitoring will ensure that any changes in the client’s condition are promptly addressed.
Choice D rationale
Increasing the frequency of fundal massage is not needed in this case. The fundus is already firm and midline, indicating that the uterus is well-contracted. Excessive fundal massage can cause discomfort and is unnecessary when the uterus is already in a good position.