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. Breast milk typically "comes in" or becomes more abundant between 3 to 5 days after birth as colostrum transitions to mature milk.
B. Within 2 days is too soon for most women to experience their milk "coming in."

C. 6 to 8 days is later than the typical timeframe for milk production to increase significantly.

D. About 10 days is longer than the average time for breast milk to "come in" for most postpartum women.

A. Fundus palpable to right of midline B. Less than 2.5 cm of rubra lochia on perineal pad C. Client report of frequent uterine contractions D. Client report of increased thirst

Correct Answer is A

Explanation

A. The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.

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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

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