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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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

These actions can help reduce the risk of infection for the client who has prolonged labor.

• ChoiceBis correct because changing perineal pads every 2 hours can prevent bacterial growth and contamination of the genital tract.

• ChoiceCis correct because encouraging oral fluid intake can help maintain hydration and blood volume, which can improve uterine perfusion and prevent maternal and fetal acidosis.

• ChoiceDis correct because administering IV antibiotics as prescribed can prevent or treat maternal peripartum infections, which are among the leading causes of maternal mortality worldwide.

• ChoiceEis correct because using sterile gloves when providing perineal care can prevent introducing pathogens into the genital tract.

A. A boggy uterus that does not respond to massage B. A pulse rate of 120 beats per minute C. A blood pressure of 90/60 mm Hg D. A lochia flow heavier than a normal menstrual period

Correct Answer is A

Explanation

A boggy uterus that does not respond to massage is an early indicator of postpartum hemorrhage.

A boggy uterus means that the uterus is not contracting properly after delivery, which can lead to excessive bleeding from the site where the placenta was attached.This condition is called uterine atony and it is the most common cause of postpartum hemorrhage.

Massage can help stimulate the uterus to contract and stop the bleeding, but if it does not work, other interventions are needed.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is evaluating a client who has prolonged and obstructed labor for signs of postpartum hemorrhage. Which of the following findings is an early indicator of postpartum hemorrhage?

Correct Answer is A

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.