A nurse is caring for a 30-year-old female client who is 36 hours postpartum in the postpartum unit.
After reviewing the information in the client’s medical record, which of the following complications poses a greater risk for the client? Complete the following sentence by using the list of options:
The complication that poses the greatest risk for the client is
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The complication that poses the greatest risk for the client is hemorrhage as evidenced by their amount of lochia.
Rationale for correct answers
Postpartum hemorrhage (PPH) is a major concern when excessive lochia and a boggy uterus are present. The nurse’s assessment reveals a boggy fundus, which firmed with massage but then softened again, indicating uterine atony, a leading cause of PPH. Additionally, the saturation of the perineal pad with lochia rubra and small clots suggests ongoing bleeding that requires close monitoring.
Rationale for incorrect Response 1 options
- Infection: No fever (≥38°C or 100.4°F) or foul-smelling lochia, which would indicate postpartum endometritis.
- Thrombophlebitis: No calf pain, swelling, or localized tenderness suggesting deep vein thrombosis.
- Mastitis: Breasts are soft, warm, and tender but without redness or localized pain, making mastitis unlikely.
Rationale for incorrect Response 2 options
- Breast tenderness: Expected due to milk production, not indicative of infection or complications.
- Calf pain: No evidence of thrombophlebitis or deep vein thrombosis.
- Fever: Temperature is normal at 37.2°C, ruling out systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.
Choice B rationale
Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.
Choice C rationale
Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.
Choice D rationale
Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.
Correct Answer is B
Explanation
Choice A rationale
Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.
Choice B rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.
Choice C rationale
Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.
Choice D rationale
Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.
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