The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse immediately follow-up with?
The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse immediately follow-up with?
A. White blood cell count 14,000 mm3 (14.0 x 10⁹/L) [5,000-10,000 mm3, 3.5–10.5 × 10⁹/L]
[34%]
B. Blood Urea Nitrogen (BUN) 18 mg/dL (6.426 mmol/L) [10-20 mg/dL, 2.1–8.0 mmol/L]
[1%]
C. Capillary blood glucose 258 mg/dL (14.29 mmol/L) [70-110 mg/dL, 4.0–11.0 mmol/L]
[57%]
D. Urinary output 60 mL/hr [2.03 oz/hr]
[8%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Postpartum
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Analysis
Explanation
Choice C is correct. This blood glucose is greater than 250 mg/dL and is clinical hyperglycemia. Regardless if the client has a history of diabetes mellitus, this CBG requires immediate follow-up because it is the only significant abnormal clinical data.
Choice A is incorrect. While slightly elevated, this white blood cell count may be a normal response to the stress of delivery and does not necessarily require immediate follow-up. Leukocytosis is a common and benign postpartum finding. The white blood cell count may be as high as 30,000/mm3 (30 x 10⁹/L) during labor and usually returns to normal limits by six days postpartum. However, the nurse should continue monitoring for any signs of infection or other complications.
Choice B is incorrect. The BUN level of 18 mg/dL (6.426 mmol/L) falls within the normal range [10-20 mg/dL or 2.1-8.0 mmol/L] and does not require immediate follow-up.
Choice D is incorrect. Urinary output of 60 mL/hr [2.03 oz/hr] considered within the normal range and indicates adequate renal function. There is no immediate need for follow-up regarding urinary output.
Additional Info
✓ Normal postpartum findings include -
- A urinary output of up to 3000 mL/day may occur, especially on days 2 through 5 postpartum.
- Diaphoresis is a common postpartum finding
- White blood cell (WBC) count increases to as high as 30,000/mm3 during labor and the immediate postpartum period
- The hematocrit returns to normal limits 4 to 6 weeks postpartum
- The first stool usually occurs within 2 to 3 days postpartum. Constipation is common during the first bowel movement.
- Approximately 4.5 to 5.8 kg (10 to 13 lb) is lost during childbirth. This includes the weight of the fetus, placenta, amniotic fluid, and blood lost during the birth
- An additional 2.3 to 3.6 kilograms (kg) (5 to 8 lb) are lost as a result of diuresis and 0.9 kg to 1.4 kg (2 to 3 lb) from involution and lochia by the end of the first week
✓ In the first 24 hours after childbirth, a woman's body begins the process of physical recovery. The uterus starts to contract back to its pre-pregnancy size, which can cause discomfort and cramping known as afterpains. The healthcare team monitors the woman's vital signs, bleeding, and uterine contractions to ensure her body is healing properly.
✓ The first 24 hours after childbirth are crucial for bonding between the mother and the newborn. Skin-to-skin contact is encouraged, which helps regulate the baby's body temperature and promotes breastfeeding.
