A nurse is collecting data from a postpartum client.
Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Fundus at umbilicus level
Urinary output 3,000 mL
Temperature 100.4 F for two days
Cesarean section shortly following delivery
The Correct Answer is B
Choice A rationale:
The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus
(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and
descend into the pelvic cavity, guided by the process known as involution.
Choice B rationale:
A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common
as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of
postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized
by high blood pressure and signs of damage to another organ system, often the kidneys.
Choice C rationale:
A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a
slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above 100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.
Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.
The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,
regular contractions and the urge to push.
Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head
compression, cord compression, and uteroplacental insufficiency.
Choice B rationale:
The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.
This can help to improve fetal heart rate and prevent further decelerations.
Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.
When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.
Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.
Choice D rationale:
The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the
fetus.
Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health
and how she is coping with labor.
The fetal heart rate is a direct measure of the fetus's well-being.
By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.
Additional notes:
The nurse should also encourage the client to change positions, as this can help to relieve cord compression.
The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a
sign of fetal distress.
Correct Answer is A
Explanation
Choice A rationale:
Retraction of the fetal head against the maternal perineum is a classic sign that the shoulders are about to be delivered. This is
known as the "turtle sign" because the fetal head appears to retract back into the body like a turtle's head.
It is important for the nurse to be prepared to assist with the delivery of the shoulders to ensure a safe and smooth delivery.
This includes:
Positioning the mother appropriately, such as in the McRoberts maneuver or a hands-and-knees position.
Applying gentle downward traction on the fetal head to help deliver the anterior shoulder.
Rotating the fetal shoulders as needed to facilitate delivery.
Monitoring the fetal heart rate closely for any signs of distress.
Choice B rationale:
While encouraging the mother to rest between contractions is important for conserving energy, it is not the priority action
when the fetal head is retracting. The nurse's focus should be on preparing for the delivery of the shoulders.
Choice C rationale:
Checking the mother's blood pressure is a routine part of labor and delivery care, but it is not specifically indicated when the
fetal head is retracting. There is no evidence to suggest that retraction of the fetal head is associated with changes in maternal
blood pressure.
Choice D rationale:
Administering oxygen to the mother may be helpful in some cases, such as if the fetal heart rate is showing signs of distress.
However, it is not the priority action when the fetal head is retracting. The focus should be on preparing for the delivery of the
shoulders.
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