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 D
Explanation
Choice A rationale
An increase in baseline variability is generally considered a reassuring sign of fetal well-being, indicating a responsive central nervous system and adequate oxygenation. While important to monitor, it is not a specific periodic pattern to observe immediately following membrane rupture due to potential cord compression. Normal baseline variability ranges from 6 to 25 beats per minute.
Choice B rationale
Non-periodic accelerations are abrupt increases in fetal heart rate above the baseline, typically lasting less than 30 seconds. They are usually a reassuring sign, often occurring with fetal movement or stimulation. While their presence is noted, they are not the primary periodic pattern to observe immediately after membrane rupture for potential complications.
Choice C rationale
Early decelerations are gradual decreases in fetal heart rate that mirror the uterine contractions. They are thought to be caused by fetal head compression and are generally considered benign. While their presence is documented, they are not the most concerning pattern immediately after membrane rupture, which raises the risk of cord issues.
Choice D rationale
Variable decelerations are abrupt decreases in fetal heart rate that are variable in timing and shape in relation to uterine contractions. They are often caused by umbilical cord compression, which is a significant risk factor immediately following the rupture of membranes, as the fluid cushion around the cord is reduced. Prompt identification is crucial for intervention.
Correct Answer is D
Explanation
Choice A rationale
While understanding methods of labor induction is important if the pregnancy progresses to 42 weeks, it is not the priority teaching at 31 weeks gestation. The immediate focus should be on recognizing potential complications that could arise before the scheduled induction.
Choice B rationale
The benefits of breastfeeding are important for all pregnant women but are not the priority teaching for a client at 31 weeks who is not yet in labor. Information about breastfeeding can be provided later in the pregnancy.
Choice C rationale
Teaching the signs of labor is important as the client approaches term, but at 31 weeks, the priority is to educate the client on recognizing potential warning signs that require immediate attention, such as decreased fetal movement.
Choice D rationale
Monitoring fetal movement is a crucial teaching point at 31 weeks gestation. A decrease in fetal movement can be an early indicator of fetal compromise and requires prompt evaluation. Instructing the client on how to perform kick counts and when to report changes is a priority for ensuring fetal well-being before the scheduled induction.
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