Choice A rationale

Postpartum hemorrhage is a serious condition characterized by heavy bleeding after childbirth. In the scenario described, the nurse’s notes indicate that the client’s fundus is boggy and located 1 cm above the umbilicus, which becomes firm with massage. This could be a sign of uterine atony, a leading cause of postpartum hemorrhage. Additionally, the client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10, and the perineal pad shows a moderate amount of lochia rubra. These are all signs that could indicate a postpartum hemorrhage.

Choice B rationale

While infection is a possible postpartum complication, the symptoms provided do not strongly indicate an infection. Symptoms of a postpartum infection typically include soreness, tenderness, or swelling of the belly or abdomen, chills, pain while urinating or during sex, abnormal vaginal discharge that has a bad smell or blood in it, and a general feeling of discomfort or unwellness.

Choice C rationale

Thrombophlebitis is a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow. It commonly occurs in the legs but can occur elsewhere in the body. The symptoms include swelling of the affected area, redness of the affected area, tenderness of the affected area, warmth around the affected area, and pain. However, the symptoms provided do not strongly indicate thrombophlebitis.

Choice D rationale

Pulmonary embolism is a serious condition that occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung. Symptoms can include shortness of breath or chest pain. However, the symptoms provided do not strongly indicate a pulmonary embolism.

Choice A rationale

While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

Choice B rationale

Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.

Choice C rationale

This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.

Choice D rationale

Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.