A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.

What complication should the nurse prioritize during the client’s assessment?

Hard, painful uterine afterpains.

Disseminated intravascular coagulation.

Postpartum psychosis.

Placenta accreta.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While hard, painful uterine afterpains can be uncomfortable for the patient, they are a normal part of the postpartum period and are not typically a priority complication following a severe postpartum hemorrhage16.

Choice B rationale

Disseminated intravascular coagulation (DIC) is a serious condition that can occur as a complication of severe postpartum hemorrhage. It involves an overactive clotting process leading to the formation of small blood clots that can block blood vessels and cause significant organ damage16.

Choice C rationale

Postpartum psychosis is a serious mental health disorder that can occur after childbirth. However, it is not directly related to postpartum hemorrhage and would not typically be the priority complication in this scenario16.

Choice D rationale

Placenta accreta is a condition where the placenta grows too deeply into the uterine wall. While it can cause severe bleeding after delivery, it would not typically be a priority complication to assess for following a severe postpartum hemorrhage16.

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Correct Answer is D

Explanation

Choice A rationale

Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.

Choice B rationale

Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.

Choice C rationale

Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.

Choice D rationale

Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.

A. Clean up the spit-up and assist the mother with the diaper change. B. Position the newborn on the side and suction the mouth and nares with a bulb syringe. C. Position the newborn with the head lower than the feet. D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

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A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.What complication should the nurse prioritize during the client’s assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

Correct Answer is D

Explanation

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

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During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time. I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

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A client who is anovulatory and has hyperprolactinemia is undergoing infertility treatment with metformin, menotropins, and human chorionic gonadotropin.What side effect should the nurse instruct the client to report immediately?

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A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.

What complication should the nurse prioritize during the client’s assessment?