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. Molding B. Caput succedaneum C. Pilonidal dimple D. Cephalhematoma

Correct Answer is D

Explanation

A. Molding refers to the shaping of the fetal head during labor and delivery to facilitate passage through the birth canal. It typically resolves within a few days and does not involve bruising.
B. Caput succedaneum is localized swelling or edema of the scalp that crosses suture lines and typically resolves within a few days. It is not associated with bruising.
C. Pilonidal dimple refers to a small pit or depression in the skin, typically at the base of the spine, and is not related to the finding described.
D. Cephalhematoma is a collection of blood between the skull bone and its periosteum. It is

confined by suture lines and may take weeks to resolve. It does not cross suture lines and may be associated with bruising due to birth trauma.

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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

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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