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
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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Related Questions
Correct Answer is C
Explanation
A. Absent plantar reflexes may indicate neurological issues but are not specifically associated with developmental dysplasia of the hip (DDH).
B. Lengthened thigh on the affected side is not a typical finding in DDH. Instead, there may be apparent shortening due to hip dislocation.
C. Asymmetric thigh folds are a common finding in DDH due to hip instability, causing the femoral head to be displaced from the acetabulum and resulting in uneven thigh folds.
D. An inwardly turned foot on the affected side may be seen in conditions like clubfoot but is not a characteristic finding in DDH.
Correct Answer is D
Explanation
A. Administering oxytocic medication may be necessary to stimulate uterine contractions and control bleeding, but palpating the client's uterine fundus is the priority to assess for uterine atony or excessive bleeding.
B. Increasing the client's fluid intake is important for hydration but does not address the immediate concern of potential postpartum hemorrhage.
C. Assisting the client on a bedpan to urinate is important for comfort and bladder emptying but does not address the priority of assessing and managing postpartum bleeding.
D. Palpating the client's uterine fundus is the priority nursing intervention to assess for uterine atony or excessive bleeding, which could indicate postpartum hemorrhage.
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