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
Explanation
Choice A rationale:
Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the
provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.
Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that
can endanger both the mother and the fetus.
Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,
decreased variability, or bradycardia.
Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene
to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop
or slow down labor, or performing a cesarean delivery.
Choice B rationale:
Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period
between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could
be a sign of tachysystole (excessively frequent contractions), which may also require intervention.
Choice C rationale:
Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase
with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant
tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.
Choice D rationale:
Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as
having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical
change. In early labor, contractions may be more sporadic and less intense.
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.
Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.
Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.
Choice D rationale:
Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after
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