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

Question

Options

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

• A
  3% (2)
• B
  71% (47)
• C
  9% (6)
• D
  17% (11)

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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