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
Wrapping the baby in warmed blankets addresses heat loss through conduction (direct contact with a cooler surface) and radiation (heat transfer to cooler surroundings). While helpful for maintaining warmth, it does not directly prevent heat loss from convection.
Choice B rationale
Convection is the loss of heat to cooler air currents moving across the skin surface. A blowing fan increases the rate of convective heat loss by continuously moving cooler air over the newborn. Moving the infant away from a blowing fan minimizes this heat transfer mechanism, thus preventing heat loss from convection.
Choice C rationale
Drying the baby after a bath primarily prevents heat loss through evaporation, as the evaporation of water from the skin surface cools the body. While important for thermoregulation, it does not directly address convective heat loss.
Choice D rationale
Placing the baby in a warmer, such as a radiant warmer, primarily prevents heat loss through radiation by providing a warm surface that emits infrared heat towards the infant. It also helps maintain the ambient air temperature, indirectly reducing convective heat loss, but moving away from a direct air current is the most direct way to prevent convection.
Correct Answer is D
Explanation
Choice A rationale
Rapid plasma regain is not a standard laboratory test associated with hyperemesis gravidarum. Hyperemesis gravidarum involves significant fluid and electrolyte losses, but rapid plasma regain is not a specific indicator of this condition.
Choice B rationale
A urine culture is used to detect the presence of bacteria in the urine, typically to diagnose a urinary tract infection. While dehydration from hyperemesis gravidarum can increase the risk of a UTI, a urine culture is not a primary anticipated laboratory test for hyperemesis itself.
Choice C rationale
Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. It is used to assess coagulation and is not directly related to the metabolic and electrolyte imbalances caused by hyperemesis gravidarum.
Choice D rationale
Urine ketones are a byproduct of fat breakdown for energy, which occurs when the body is not getting enough glucose. In hyperemesis gravidarum, persistent vomiting can lead to dehydration and starvation, forcing the body to break down fat for energy, resulting in ketonuria (ketones in the urine).
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