A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.
Exhibits
The nurse is assessing the client 1 hour later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
Fundus 2 cm above umbilicus
Blood pressure 90/60 mm Hg
Heart rate 110/min
Continued heavy vaginal bleeding
Client reports feeling dizzy
Cloudy urine
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
• Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
• Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
• Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
• Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
• Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
• Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Moving the client onto their hands and knees is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice B rationale
Applying pressure to the client’s fundus is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice C rationale
This is the correct answer. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice D rationale
Pressing firmly on the client’s suprapubic area is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Correct Answer is A
Explanation
Choice A rationale
A blood pressure of 88/40 mm Hg is significantly lower than the normal range, which could indicate hemorrhage. Hypotension is a common sign of significant blood loss.
Choice B rationale
Moderate rubra lochia is normal within the first few days postpartum and does not necessarily indicate hemorrhage.
Choice C rationale
A heart rate of 90/min is within the normal range and does not indicate hemorrhage.
Choice D rationale
A urinary output of 40 mL/hr is within the normal range and does not indicate hemorrhage.
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