Question

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.

A. Urination of 100 mL every 4 hours
B. Moderate saturation of peripad every 3 hours
C. Hypotonic bowel sounds
D. Fundus one fingerbreadth below the umbilicus
E. Inverted nipples following breastfeeding

Answer 1

After birth, it's acceptable for a woman to have the fundus one fingerbreadth below the umbilicus and urinate 100 mL every 4 hours. Hypotonic bowel sounds may occur, while moderate peripad saturation and inverted nipples could warrant further attention.

Step-by-step explanation:

Among the assessment findings deemed acceptable for a woman in the first 24 hours after birth are: urination of 100 mL every 4 hours (A), which indicates adequate kidneys function and fluid balance, and fundus one fingerbreadth below the umbilicus (D), which shows that the uterus is contracting and returning to its non-pregnant size. Hypotonic bowel sounds (C) may be experienced as the bowels can be slow to return to normal activity postpartum. However, moderate saturation of peripad every 3 hours (B) could be a concern if excessive as it may indicate postpartum hemorrhage, and inverted nipples following breastfeeding (E) is not typically an expected finding and may indicate a need for support with breastfeeding technique.