A nurse is caring for a 34-year-old female client who is 2 days postpartum in the postpartum unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Rationale for Correct Condition
Subinvolution refers to delayed uterine involution, often due to retained placental fragments or infection. The boggy uterus, excessive lochia, and passage of clots are hallmark signs. The history of postpartum hemorrhage increases risk, and fundal tenderness suggests uterine atony rather than infection or hematoma formation.
Rationale for Correct Actions
Oxytocin enhances uterine contractions to reduce bleeding and facilitate involution by increasing myometrial tone. Methylergonovine is a potent uterotonic that further supports contraction, decreasing hemorrhage risk, but must be used cautiously in hypertensive patients.
Rationale for Correct Parameters
Saturated perineal pads track blood loss severity, guiding interventions for ongoing hemorrhage. Excessive bleeding may require further medical management. Hemoglobin and hematocrit assess for anemia due to blood loss, guiding transfusion decisions if needed.
Rationale for Incorrect Conditions
Postpartum preeclampsia presents with hypertension and proteinuria, not uterine atony. Perineal hematoma manifests as localized swelling with severe perineal pain, which is absent here. Thrombophlebitis involves unilateral extremity swelling and pain, not fundal tenderness or abnormal lochia.
Rationale for Incorrect Actions
Ice packs to the perineum manage hematomas, not uterine atony. Anticoagulants are used for thromboembolic prevention, not postpartum bleeding. Quiet environment is relevant for preeclampsia, not uterine subinvolution.
Rationale for Incorrect Parameters
Seizures are relevant to preeclampsia, not uterine subinvolution. Calf circumference is monitored for thrombophlebitis, which is absent here. Rectal pain is not an expected indicator of uterine involution status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Misoprostol is a prostaglandin analog that stimulates uterine contractions. It is contraindicated in clients with placenta previa due to the risk of severe hemorrhage from placental separation if contractions are induced.
Choice B rationale
Active genital herpes is a contraindication for vaginal delivery and therefore also a contraindication for induction of labor with Misoprostol, as it could potentially lead to vertical transmission of the herpes simplex virus to the newborn during passage through the birth canal.
Choice C rationale
A previous uterine incision due to multiple myomectomy can be a contraindication for labor induction with Misoprostol, depending on the type and location of the incisions. The increased risk of uterine rupture with strong contractions stimulated by Misoprostol is a significant concern in such cases.
Choice D rationale
Gestational hypertension, in the absence of other contraindications, can be an indication for induction of labor if the benefits of delivering the baby outweigh the risks of continuing the pregnancy. Misoprostol can be used cautiously in this situation to ripen the cervix and induce labor.
Correct Answer is B
Explanation
Choice A rationale
The stepping reflex, also known as the walking or dancing reflex, is elicited by holding the infant upright with their feet touching a flat surface. The infant will make stepping or dancing movements. This is not elicited by stroking the lateral sole of the foot.
Choice B rationale
The Babinski reflex is elicited by stroking the lateral sole of the infant's foot from the heel upward and across the ball of the foot. A positive Babinski sign is characterized by dorsiflexion of the great toe and fanning out of the other toes. This reflex is normal in infants and typically disappears by 12 to 24 months of age.
Choice C rationale
The tonic neck reflex, also known as the fencing reflex, is elicited by turning the infant's head to one side. The arm and leg on the turned side extend, while the arm and leg on the opposite side flex. Stroking the sole of the foot does not elicit this reflex.
Choice D rationale
The plantar grasp reflex is elicited by placing a finger or object across the base of the infant's toes. The toes will curl downward and grasp the object. This reflex is different from the response elicited by stroking the lateral sole of the foot. .
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