A 35-year-old postpartum client has the following assessment findings: Temperature 99.8 F (37.7 C), Heart Rate 80, Respiratory Rate 16, Blood Pressure 150/86, SpO2 100% on room air.
Based on these findings and the client's history of prolonged labor and being a primipara, which condition is the client most likely experiencing?

Placenta previa.

Placental abruption.

Postpartum hemorrhage.

Preeclampsia.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Placenta previa is a condition where the placenta implants in the lower part of the uterus, potentially covering the cervix. This typically presents with painless vaginal bleeding, not the elevated blood pressure seen in this client.

Choice B rationale

Placental abruption involves the premature separation of the placenta from the uterine wall. This often manifests with sudden abdominal pain, vaginal bleeding, and uterine tenderness, which are not the primary findings in this postpartum client.

Choice C rationale

Postpartum hemorrhage is excessive bleeding after childbirth, typically defined as more than 500 mL after vaginal delivery or 1000 mL after cesarean birth. While prolonged labor can increase the risk, the client's current vital signs do not indicate active hemorrhage.

Choice D rationale

Preeclampsia can occur postpartum, characterized by new-onset hypertension (blood pressure ≥ 140/90 mmHg) and proteinuria or other signs of end-organ damage within 4 weeks after delivery. This client's blood pressure of 150/86 mmHg, coupled with a history of prolonged labor and being a primipara (both risk factors for preeclampsia), makes this the most likely condition. Normal postpartum blood pressure typically returns to the client's baseline pre-pregnancy levels.

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Correct Answer is A

Explanation

Choice A rationale

Rubella immunization is contraindicated during pregnancy due to the theoretical risk to the fetus from the live attenuated vaccine. Administering the vaccine immediately after delivery ensures the mother develops immunity before subsequent pregnancies, protecting future fetuses from congenital rubella syndrome.

Choice B rationale

Administering the rubella vaccine during the first trimester of pregnancy is contraindicated because it is a live attenuated vaccine and poses a potential risk to the developing fetus, potentially causing congenital rubella syndrome which can lead to serious birth defects.

Choice C rationale

Administering the rubella vaccine during the third trimester of pregnancy is also contraindicated due to the potential risk to the fetus. While the risk might be lower later in pregnancy, it is still not recommended to administer live vaccines during gestation.

Choice D rationale

Waiting until the next attempt to get pregnant is not the optimal timing. The recommendation is to administer the rubella vaccine immediately postpartum to ensure the mother is immune before any future pregnancies, thus preventing potential harm to subsequent fetuses. .

A. "We will check for a reduction in swelling and fluid retention.”. B. "You should feel less pain and have fewer headaches.”. C. "We will monitor your blood pressure to see if it decreases.”. D. "We will assess for a decrease in seizure activity and improved reflexes.”.

Correct Answer is D

Explanation

Choice A rationale

While magnesium sulfate can sometimes lead to a mild diuresis, its primary therapeutic effect in severe preeclampsia is not a direct reduction in swelling and fluid retention. These symptoms are more effectively managed by addressing the underlying hypertension and potential fluid overload through other interventions.

Choice B rationale

Magnesium sulfate is primarily used as an anticonvulsant and to lower blood pressure in severe preeclampsia. While it might indirectly alleviate some discomfort associated with preeclampsia, a direct reduction in pain and headaches is not the primary indicator of its therapeutic effectiveness.

Choice C rationale

Magnesium sulfate does have antihypertensive properties and can help lower blood pressure in severe preeclampsia. However, its most critical role is in preventing seizures. Therefore, monitoring blood pressure alone is not the most appropriate way to determine if the medication is working effectively in preventing seizures. Normal blood pressure is typically less than 120/80 mmHg.

Choice D rationale

Magnesium sulfate is administered in severe preeclampsia primarily to prevent seizures and may also have a relaxing effect on smooth muscles, which can improve hyperreflexia. A decrease in seizure activity and the normalization of deep tendon reflexes (normal range is 2+) are key indicators that the magnesium sulfate is achieving its therapeutic goals.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the first trimester of pregnancy and discovers that the client lacks immunity to rubella based on her blood work.When is the recommended time for administering rubella immunization?

Correct Answer is A

Explanation

A nurse is monitoring a client who is receiving magnesium sulfate for severe preeclampsia.The client asks, "How will I know if the medication is working?" Which response by the nurse is most appropriate?

Correct Answer is D

Explanation

A nurse is monitoring a client in active labor who has an epidural in place.Which of the following findings should be reported to the anesthesiologist immediately?

A first-time mother presents for a labor check.She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Which assessment findings might raise the nurse's suspicion of endometriosis in the client they are evaluating?

A nurse is educating a pregnant client about the differences between Braxton Hicks contractions and true labor contractions.Which statement should the nurse include?

A 56-year-old menopausal woman reports to the registered nurse that she has been experiencing vaginal itching, burning, and an increase in vaginal infections over the past 3 years. What important factor should the nurse consider before responding to the client's concerns?