NCLEX-RN Question #516: Real Exam Question with Answer & Explanation

The correct answer is B. Uterine fundus palpable left of midline. (A) Bradycardia of 50-70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. (B) The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postparta

Question

At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?

Options

AApical pulse of 52 bpm
BUterine fundus palpable left of midline
CNo bowel movement since delivery
DOral temperature of 100.4F

Explanation

(A) Bradycardia of 50-70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. (B) 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. (C) Re-establishment of normal bowel function is delayed into the first postpartum week. (D) 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.

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