Difficulty: Medium
Average Score: 74%
Full-length
At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
Correct answer
B
Rationale
Bradycardia of 50-70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. Re-establishment of normal bowel function is delayed into the first postpartum week. A postpartum woman's oral temperature may go as high as 100.4°F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.