A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony.

Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.

A boggy uterus

A firm fundus at the umbilicus

Excessive lochia rubra

Clots larger than a quarter

A pulse rate of 110/min

Answer and Explanation

Correct Answer : A

A boggy uterus is a sign of uterine atony, which is the failure of the uterus to contract sufficiently after childbirth.

This can lead to excessive bleeding and postpartum hemorrhage.

A firm fundus at the umbilicus is a normal finding after delivery and indicates that the uterus is contracting well.

Excessive lochia rubra is also a sign of uterine atony and postpartum hemorrhage. Lochia rubra is the vaginal discharge composed of blood, mucus, and tissue from the placenta and the uterus lining that occurs after childbirth.

It is normal for the first 3 to 4 days, but it should gradually decrease in amount and change in color.

Clots larger than a quarter are abnormal and indicate excessive bleeding.

A pulse rate of 110/min is a sign of tachycardia, which can be caused by blood loss, infection, or pain.

A normal pulse rate for an adult is between 60 and 100 beats per minute.

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Correct Answer is B

Explanation

a vesicovaginal fistula is an abnormal opening that forms between the bladder and the wall of the vagina, causing urine to leak out of the vagina.Zinc oxide cream can help protect the skin from irritation and infection.

Normal ranges for fluid intake are about 2 to 3 liters per day for healthy adults, depending on age, activity level, and climate.Normal ranges for pelvic floor muscle strength are 10 to 12 contractions of 6 to 8 seconds each, with a rest period of 4 to 6 seconds between each contraction.

A. Placental abruption B. Umbilical cord prolapse C. Ruptured vasa previa D. Bleeding from the cervix.

Correct Answer is C

Explanation

This is a condition where fetal blood vessels that run through the membranes rupture and bleed.

The bleeding is from the fetus, not the mother, and can cause fetal hypoxia and death.

The FHR deceleration indicates fetal distress.

The uterus is soft because there is no uterine bleeding or contraction.

Normal ranges for FHR are 110 to 160 beats per minute.

Normal ranges for uterine contraction frequency are 2 to 5 contractions in 10 minutes.

Normal ranges for uterine contraction duration are 45 to 80 seconds.

Normal ranges for uterine contraction intensity are mild to moderate to palpation

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A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony. Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has prolonged and obstructed labor and develops a vesicovaginal fistula. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A gush of blood is noted with the rupture of membranes. On palpation, the uterus is soft (i.e., relaxed) and the patient is not reporting any pain. An FHR deceleration down to 90 bpm is noted. What does the nurse suspect has happened?

Correct Answer is C

Explanation

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A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony.

Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.