A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Urine output of 3,000 mL in 12 hours

Fundus palpable at the umbilicus

Orthostatic hypotension

Heart rate 110/min

Answer and Explanation

The Correct Answer is D

A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.

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Correct Answer is A

Explanation

A. Changing the perineal pad is a task that can be safely delegated to an assistive personnel (AP) as it involves basic hygiene care and does not require nursing judgment.
B. Observing an area of redness on the breast may require nursing assessment and judgment to determine if further intervention is needed.
C. Monitoring vital signs during admission of a client with gestational hypertension requires nursing assessment and judgment to detect any signs of worsening condition or complications.
D. Providing a sitz bath to a client with a fourth-degree laceration requires nursing assessment and judgment to ensure appropriate wound care and pain management.

A. Cover the cord with the diaper. B. Give a sponge bath until the cord stump falls off. C. Wash the cord daily with mild soap and water. D. Apply petroleum jelly to the cord stump.

Correct Answer is B

Explanation

A. Covering the cord with the diaper can increase moisture around the stump, leading to delayed cord separation and potential infection.
B. Giving a sponge bath until the cord stump falls off helps to keep the area clean and dry, reducing the risk of infection.
C. Washing the cord daily with mild soap and water is not recommended as it can increase the risk of infection and delay cord separation.
D. Applying petroleum jelly to the cord stump is not recommended as it can trap moisture and increase the risk of infection.

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A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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