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 D
Explanation
Choice A rationale:
Evaluating the side effects of analgesia is not the priority action in this situation. While it's important to assess for potential
side effects, the client's immediate need to use the bathroom takes precedence.
Analgesia might contribute to urinary retention in some cases, but it's not the most likely reason for the client's request.
Promptly addressing the client's need to void helps prevent bladder distention, discomfort, and potential urinary tract
infections.
Choice B rationale:
Using a wheelchair is not necessary in most cases after a vaginal birth.
Early ambulation is generally encouraged to promote circulation, prevent blood clots, and aid in recovery.
Requiring a wheelchair could delay the client's ability to void and might make her feel less independent.
Choice C rationale:
Advising the client to remain in bed is not recommended practice after a vaginal birth.
Prolonged bed rest can increase the risk of complications, such as blood clots, muscle weakness, and delayed bowel function.
Early ambulation, as tolerated, is crucial for promoting physical recovery and preventing postpartum complications.
Correct Answer is D
Explanation
Choice A rationale:
Rh positive individuals already have the Rh factor on their red blood cells, so they do not need Rho(D) immune globulin to
prevent sensitization.
The newborn being Rh positive does not pose a risk to an Rh positive mother, as their blood types are compatible.
Choice B rationale:
Rh positive individuals cannot develop antibodies against the Rh factor, as it is already present on their own red blood cells.
The newborn's Rh negative status does not create a risk of sensitization for the mother, as there is no Rh factor to trigger an
immune response.
Choice C rationale:
If both the mother and the newborn are Rh negative, there is no risk of Rh incompatibility.
This is because neither individual has the Rh factor on their red blood cells, so there is no potential for sensitization.
Choice D rationale:
When an Rh negative mother carries an Rh positive fetus, there is a risk of Rh sensitization during pregnancy and delivery.
This occurs when fetal blood cells cross the placenta and enter the mother's bloodstream, exposing her immune system to the
Rh factor.
If the mother's immune system recognizes the Rh factor as foreign, it can produce antibodies against it.
These antibodies can cross the placenta in subsequent pregnancies and attack the red blood cells of Rh positive fetuses,
leading to hemolytic disease of the newborn (HDN).
Rho(D) immune globulin is a medication that can prevent Rh sensitization by binding to Rh positive fetal blood cells that have
entered the mother's bloodstream.
This prevents the mother's immune system from recognizing the Rh factor and producing antibodies.
Rho(D) immune globulin is typically given to Rh negative mothers within 72 hours of delivery of an Rh positive newborn, as well as after other events that could lead to Rh sensitization, such as miscarriage, abortion, or ectopic pregnancy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.