A nurse is assessing a postpartum client who had a spontaneous vaginal delivery of a baby girl. The client has a firm, midline fundus after palpation and steady trickle of bright red blood from the vagina. What is the most likely cause?
Retained placental fragments
Perineal laceration
Subinvolution
Hematoma
The Correct Answer is B
A. Retained placental fragments typically cause a soft, boggy uterus and late postpartum hemorrhage rather than a steady trickle of bright red blood with a firm fundus immediately after delivery. This does not match the assessment findings described.
B. Perineal laceration is the most likely cause. When the uterus is firm and midline, it indicates that uterine atony is not the source of bleeding. A steady trickle of bright red blood from the vagina, despite a firm uterus, suggests bleeding from a laceration of the cervix, vagina, or perineum, which is common after vaginal delivery. This finding matches the clinical scenario.
C. Subinvolution refers to the delayed return of the uterus to pre-pregnancy size, often occurring weeks after delivery. It usually presents with prolonged lochial discharge rather than immediate postpartum bleeding with a firm uterus.
D. A hematoma is a collection of blood within the soft tissues of the perineum or vulva. It usually presents with localized swelling, pain, and sometimes vaginal pressure, rather than a continuous, visible trickle of bright red blood. The absence of a firm, localized swelling makes this less likely in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Emptying surgical drains is an important part of postoperative care and should be performed as instructed to prevent fluid accumulation and infection. This activity is safe and encouraged.
B. Progressive arm exercises are recommended to maintain shoulder mobility and prevent stiffness or lymphedema. These exercises should be done gradually according to the nurse’s instructions.
C. Lifting less than 2 lbs is safe and typically recommended early in the postoperative period to avoid strain on the surgical site.
D. Wearing clothing with tight sleeves on the operative side should be avoided because tight clothing can restrict circulation, increase swelling, and elevate the risk of lymphedema. Patients are advised to wear loose, comfortable clothing to support proper healing and reduce complications.
Correct Answer is C
Explanation
A. Detection of a fetal heartbeat by ultrasound is a positive sign of pregnancy because it provides direct, objective evidence of a living fetus. Positive signs can only be attributed to pregnancy and include fetal heart tones, visualization of the fetus, and fetal movements palpated by the examiner.
B. A positive pregnancy test is a probable sign of pregnancy. It detects human chorionic gonadotropin (hCG) in blood or urine, which is usually produced during pregnancy, but false positives can occur due to hCG-secreting tumors, recent pregnancy loss, or fertility medications.
C. Breast tenderness and enlargement are presumptive signs of pregnancy. Presumptive signs are subjective symptoms reported by the woman and are not diagnostic. They result from early hormonal changes (increased estrogen and progesterone) and may also occur with premenstrual syndrome or hormonal imbalances, making them non-specific to pregnancy.
D. Abdominal enlargement is a probable sign of pregnancy because it is an objective finding observed by the healthcare provider but can be caused by other conditions such as obesity, uterine fibroids, ovarian tumors, or ascites.
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