A client who is a gravida 5, para 5 client delivers a 10-pound (4,540 gram) infant.
In planning postpartum care, which assessment has the highest priority?
Uterine muscle tone.
Vulvo-perineal tissues and episiotomy.
Body temperature.
Breast engorgement and nipple integrity.
The Correct Answer is A
Choice A rationale
Uterine muscle tone is the highest priority assessment postpartum, especially after a large infant delivery. A boggy uterus indicates uterine atony, a leading cause of postpartum hemorrhage. The uterus must contract firmly to compress blood vessels and prevent excessive bleeding. Prompt intervention is crucial to prevent hypovolemic shock. Normal uterine tone is firm and midline.
Choice B rationale
Vulvo-perineal tissues and episiotomy assessment is important to identify hematomas or excessive swelling. While significant, these are typically less life-threatening in the immediate postpartum period compared to uterine atony. Hematomas can cause pain and pressure, and wound integrity is vital for infection prevention.
Choice C rationale
Body temperature assessment is important to detect fever, which could indicate infection. Postpartum infection is a concern, but hypovolemic shock from hemorrhage is a more immediate and critical threat to maternal well-being. Normal postpartum temperature is typically below 38°C (100.4°F).
Choice D rationale
Breast engorgement and nipple integrity are important for promoting successful breastfeeding and preventing complications like mastitis. However, these are not immediate life-threatening concerns in the initial hours after delivery. Early assessment focuses on maternal physiological stability.
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Related Questions
Correct Answer is D
Explanation
Gravida refers to the total number of pregnancies a woman has had, regardless of outcome. The client has had a pregnancy that resulted in a miscarriage at 16 weeks, a pregnancy that resulted in fetal demise at 31 weeks, and the current pregnancy at 39 weeks. Therefore, the total number of pregnancies is 3. The gravida is 3.
Correct Answer is D
Explanation
Choice A rationale
Describing the percentage of saturated perineal pads is a subjective and imprecise method for estimating blood loss. Variations in pad size, absorbency, and the client's perception can lead to significant inaccuracies, making it unreliable for precise clinical assessment of hemorrhage.
Choice B rationale
While hematocrit levels are crucial for assessing overall blood volume status, obtaining an hourly hematocrit is an indirect and reactive measure of acute blood loss. It reflects hemodilution or hemoconcentration over time rather than providing a real-time, accurate quantification of the volume of blood lost. Normal hematocrit for pregnant women is 33% to 44%.
Choice C rationale
Changes in vital signs, such as tachycardia, hypotension, and tachypnea, are late indicators of significant blood loss and hypovolemic shock. Relying solely on vital signs means that a substantial amount of blood has already been lost before changes become apparent, making it an insensitive method for early detection and estimation.
Choice D rationale
Calculating the difference in weight of perineal pads before and after use provides a highly accurate objective measurement of blood loss. One gram of weight is approximately equivalent to one milliliter of blood, allowing for precise quantification and enabling timely and appropriate clinical interventions.
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