A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Urinary output 2,000 mL/12 hr
Temperature 100.4 F for two days
Chills shortly following delivery
Fundus at umbilicus level
The Correct Answer is B
Choice A reason:
A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body eliminates excess fluid accumulated during pregnancy.
Choice B reason:
A temperature of 100.4 F for two days indicates a possible infection, such as endometritis or mastitis, and requires further evaluation and treatment.
Choice C reason:
Chills shortly following delivery are common and benign and are caused by hormonal changes and fluid shifts.
Choice D reason:
A fundus at the umbilicus level is expected for a postpartum client and indicates that the uterus is involuting properly.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Position the client on her side is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Late decelerations are symmetrical decreases in the fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency and fetal hypoxia. Positioning the client on her side can improve blood flow and oxygen delivery to the placenta and fetus by relieving pressure on the vena cava and aorta.
Choice B reason: Elevate the client's legs is incorrect, as this is not a priority action for a client who has late decelerations. Elevating the legs can increase venous return and cardiac output, but it can also reduce blood flow and oxygen delivery to the placenta and fetus by compressing the vena cava and aorta.
Choice C reason: Administer oxygen via face mask is incorrect, as this is not the first action the nurse should take, although it is important to do later. Administering oxygen can increase oxygen saturation and delivery to the placenta and fetus, but it does not address the cause of uteroplacental insufficiency or improve blood flow.
Choice D reason: Increase the infusion rate of the IV fluid is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Increasing the infusion rate of IV fluid can expand blood volume and improve placental perfusion, but it does not address the cause of uteroplacental insufficiency or improve blood flow. The nurse should obtain a provider's order before increasing the IV fluid rate.

Correct Answer is B
Explanation
Choice B reason:
Auscultating the client's abdomen is the first action the nurse should take, as it can assess the return of bowel function after surgery. The nurse should listen for bowel sounds in all four quadrants, and note their frequency and quality.
Offering clear liquids is an important action, as it can provide hydration and nutrition for the client. However, this is not the first action the nurse should take, as it may cause nausea and vomiting if the client's bowel function has not returned.
Choice C reason:
Checking the client's chart for a diet prescription is an important action, as it can ensure that the client follows the provider's orders and does not consume anything contraindicated. However, this is not the first action the nurse should take, as it does not address the client's hunger or bowel function.
Choice D reason:
Giving the client soda crackers is an important action, as it can provide a bland and easily digestible food for the client. However, this is not the first action the nurse should take, as it may be too solid for the client's stomach if her bowel function has not returned.
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