A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
Placenta accreta
Hard, painful uterine afterpains.
Postpartum psychosis.
Disseminated intravascular coagulation
The Correct Answer is D
A. Placenta accreta: Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. While this can be a concern, the client in this scenario has already given birth, so this may not be the highest priority at this moment.
B. Hard, painful uterine afterpains: Afterpains are common in the postpartum period, especially in women who have given birth to multiples. While they can be uncomfortable, they are generally expected and not considered a severe complication.
C. Postpartum psychosis: Postpartum psychosis is a serious mental health condition that can occur after childbirth. It is characterized by symptoms such as hallucinations, delusions, and severe mood disturbances. While it is a serious concern, it might not be the immediate priority in a client who has had a severe postpartum hemorrhage.
D. Disseminated intravascular coagulation (DIC): This is a life-threatening condition where there is widespread activation of clotting factors, leading to excessive blood clotting followed by bleeding. Given the history of severe postpartum hemorrhage, DIC is a significant concern, and prompt assessment and intervention are crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.
Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.
Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.
Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.
Correct Answer is B
Explanation
A. Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.
B. Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.
C. Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.
D. Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.
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