A nurse is collecting data from a client who is 1 day postpartum.Which of the following findings requires immediate intervention by the nurse?
Decreased urge to void.
Displaced fundus from the midline.
Fundal height below the umbilicus.
Increased urine output.
The Correct Answer is B
Choice A rationale
A decreased urge to void is a common postpartum finding due to the effects of anesthesia and the trauma of childbirth. It does not require immediate intervention unless it leads to bladder distention.
Choice B rationale
A displaced fundus from the midline, especially if it is accompanied by a boggy uterus, indicates uterine atony, which can lead to postpartum hemorrhage. Immediate intervention is required to prevent severe blood loss.
Choice C rationale
A fundal height below the umbilicus is an expected finding 1 day postpartum as the uterus begins to involute. This does not require immediate intervention.
Choice D rationale
Increased urine output is common in the postpartum period as the body eliminates excess fluid accumulated during pregnancy. This is not a cause for immediate concern.
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Correct Answer is A
Explanation
Choice A rationale
At 1 cm above the umbilicus is the expected position of the uterine fundus 12 hours postpartum. After delivery, the fundus is typically at the level of the umbilicus and then descends approximately 1 cm per day. At 12 hours postpartum, it is normal for the fundus to be slightly above the umbilicus.
Choice B rationale
One fingerbreadth above the symphysis pubis is not the expected position of the fundus 12 hours postpartum. This position is more typical several days postpartum as the uterus continues to involute and return to its pre-pregnancy size.
Choice C rationale
To the right of the umbilicus is not a normal finding and may indicate a full bladder, which can displace the uterus. The nurse should assist the client to void and then reassess the fundal position.
Choice D rationale
Three fingerbreadths above the umbilicus is not expected 12 hours postpartum. This position may indicate uterine atony or subinvolution, which requires further assessment and intervention.
Correct Answer is D
Explanation
Choice D rationale
Applying an ice pack to the perineum is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery. Ice helps reduce swelling and provides pain relief.
Choice A rationale
Placing a soft pillow under the client’s buttocks is not effective and can increase pressure and swelling on the perineal area, worsening the pain.
Choice B rationale
Positioning a heating lamp toward the episiotomy is not recommended as it can increase the risk of burns and does not effectively reduce swelling.
Choice C rationale
Preparing a warm sitz bath can be beneficial after the first 24 hours but is not the initial action for unrelieved pain within the first 8 hours.