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 B
Explanation
Choice A rationale
This notation indicates three pregnancies (G3), one term birth (T1), two preterm births (P2), one abortion (A1), and three living children (L3). While the number of living children is correct, the total number of pregnancies is underestimated by excluding the current pregnancy.
Choice B rationale
This notation accurately reflects four pregnancies (G4: the elective abortion, the daughter, the twins, and the current pregnancy), one term birth (T1: the daughter born at 40 weeks), two preterm births (P2: the twin boys born at 34 weeks), one abortion (A1: the elective abortion), and three living children (L3: the daughter and the twin boys).
Choice C rationale
This notation indicates three pregnancies (G3), one term birth (T1), one preterm birth (P1), one abortion (A1), and three living children (L3). The number of preterm births is incorrect, as there were two preterm births (the twins).
Choice D rationale
This notation indicates four pregnancies (G4), one term birth (T1), one preterm birth (P1), one abortion (A1), and three living children (L3). The number of preterm births is incorrect, as there were two preterm births (the twins).
Correct Answer is D
Explanation
Choice A rationale
Absent early decelerations of the fetal heart rate are generally considered a reassuring sign. Early decelerations are a gradual decrease and return of the fetal heart rate associated with uterine contractions, thought to be caused by fetal head compression. Their absence does not typically warrant immediate reporting.
Choice B rationale
A fetal heart rate of 140 beats per minute falls within the normal range for a term fetus, which is typically between 110 and 160 beats per minute. This finding is reassuring and does not require immediate reporting to the provider.
Choice C rationale
Contraction frequency of 2 to 3 minutes apart indicates that the labor is progressing. While the overall pattern of contractions needs to be evaluated in conjunction with other factors like duration and intensity, a frequency within this range is not necessarily a concerning finding that requires immediate reporting on its own.
Choice D rationale
Contraction durations of 95 to 100 seconds are considered prolonged. Normal contraction duration in the active phase of labor typically ranges from 45 to 60 seconds. Prolonged contractions can reduce uterine blood flow and potentially lead to fetal hypoxia, making this a concerning finding that should be promptly reported to the provider for further evaluation.
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