A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Orthostatic hypotension
Urine output of 3,000 mL in 12 hr
Heart rate 160/min
Fundus palpable at the umbilicus
The Correct Answer is C
Choice A reason: Orthostatic hypotension is a normal finding in the postpartum period, because the client has a sudden decrease in blood volume after delivery. The nurse should instruct the client to change positions slowly and drink plenty of fluids.
Choice B reason: Urine output of 3,000 mL in 12 hr is a normal finding in the postpartum period, because the client has increased renal perfusion and diuresis after delivery. The nurse should encourage the client to empty the bladder frequently and monitor the intake and output.
Choice C reason: Heart rate 160/min is an abnormal finding in the postpartum period, because it indicates tachycardia, which can be a sign of infection, dehydration, hemorrhage, or cardiac complications. The nurse should assess the client's temperature, blood pressure, pulse, respirations, skin color, lochia, and pain level, and report any abnormal findings to the provider.
Choice D reason: Fundus palpable at the umbilicus is a normal finding in the postpartum period, because the uterus gradually involutes and descends into the pelvis after delivery. The nurse should palpate the fundus and check for firmness, position, and height. The fundus should be at the level of the umbilicus immediately after delivery, and descend about one fingerbreadth per day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Increased subcutaneous fat is not a typical finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have less subcutaneous fat, and may appear thin and wasted.
Choice B reason: Dry, cracked skin is a common finding in a newborn who was born at 42.5 weeks of gestation, because the skin has been exposed to the amniotic fluid for a prolonged period. The skin may also appear peeling, wrinkled, or leathery.
Choice C reason: Scant scalp hair is not a usual finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a preterm newborn. A postterm newborn tends to have more scalp hair, and may also have long nails and abundant lanugo.
Choice D reason: Copious vernix is not a specific finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have little or no vernix, which is a white, cheesy substance that protects the skin in utero.
Correct Answer is B
Explanation
Choice A reason: Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take, as it does not address the client's emotional needs or preferences. The nurse should first assess the client's coping and grieving process, and provide support and comfort.
Choice B reason: Offering the mother private time with the newborn is the first action that the nurse should take, as it can facilitate the bonding and closure process, and help the client express her feelings and emotions. The nurse should respect the client's wishes and cultural beliefs regarding the viewing and holding of the stillborn infant, and provide a quiet and private environment.
Choice C reason: Administering alprazolam 0.5 mg PO is not the first action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the client's condition and history. The nurse should first use nonpharmacological methods, such as active listening, therapeutic communication, and counseling, to help the client cope and manage her anxiety and grief.
Choice D reason: Contacting the health care facility's clergy is not the first action that the nurse should take, as it may not be appropriate or desired by the client. The nurse should first ask the client if she wants any spiritual or religious support, and respect her decision and beliefs.
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