A nurse is caring for a 35-year-old female client who is immediately postpartum in the labor and delivery unit.

Exhibits

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.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Condition

Postpartum hemorrhage is defined as excessive blood loss (>500 mL in vaginal delivery) and is often caused by uterine atony, impaired uterine contraction, or trauma. This client exhibits a boggy uterus, heavy vaginal bleeding, and clot passage, all hallmark signs of postpartum hemorrhage rather than placenta previa, placental abruption, or preeclampsia.

Rationale for Correct Risk Factors

Fetal macrosomia contributes to uterine overdistension, increasing the risk of uterine atony and inefficient contractions post-delivery. History of smoking affects vascular integrity, increasing placental dysfunction risks, which can contribute to postpartum bleeding.

Rationale for Correct Assessment Findings

Uterine atony is the most common cause of postpartum hemorrhage. A boggy uterus indicates insufficient contraction to compress blood vessels after placental delivery. Heavy vaginal bleeding signifies excessive blood loss, requiring intervention to prevent hypovolemia and hemodynamic instability.

Rationale for Incorrect Conditions

Placenta previa presents with painless antepartum bleeding, not postpartum hemorrhage. Placental abruption leads to painful bleeding before delivery and can cause fetal distress. Preeclampsia involves hypertension and proteinuria, which are absent here.

Rationale for Incorrect Risk Factors

Prolonged labor can increase hemorrhage risk but is not relevant here. Primipara status does not apply, as the client is multiparous. Maternal weight may contribute but is not a primary hemorrhage risk factor.

Rationale for Incorrect Assessment Findings

Blood pressure helps assess hemorrhage severity but is not a direct finding of uterine atony. Urine output reflects fluid balance but does not confirm postpartum hemorrhage. Cramping is expected postpartum and does not indicate excessive bleeding.

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Correct Answer is C

Explanation

Choice A rationale

A positive pregnancy test is a presumptive sign of pregnancy, indicating the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy. However, conditions other than pregnancy can sometimes cause elevated hCG levels.

Choice B rationale

Hegar's sign, which is the softening of the lower uterine segment, is a probable sign of pregnancy detected by a healthcare provider during a pelvic examination. Probable signs are more objective but still not definitive proof of pregnancy.

Choice C rationale

Fetal movement felt by the provider (not the mother) is a positive sign of pregnancy. This is because the provider can objectively confirm the presence of a fetus. Other positive signs include visualization of the fetus via ultrasound and auscultation of fetal heart tones.

Choice D rationale

Breast tenderness and nausea are presumptive signs of pregnancy. These are subjective symptoms reported by the woman and can be caused by hormonal changes associated with pregnancy but can also have other causes.

A. "It increases the fetal heart rate.”. B. "It promotes fetal lung maturity.”. C. "It halts cervical dilation.”. D. "It is used to stop preterm labor contractions.”.

Correct Answer is B

Explanation

Choice A rationale

Betamethasone does not directly increase the fetal heart rate. Factors influencing fetal heart rate include fetal oxygenation, maternal hydration, and medications affecting the maternal or fetal autonomic nervous system. Normal fetal heart rate ranges from 110 to 160 beats per minute.

Choice B rationale

Betamethasone is a corticosteroid administered to pregnant women at risk of preterm delivery to accelerate fetal lung maturity. It stimulates the production of surfactant, a lipoprotein that reduces surface tension in the alveoli, preventing collapse upon expiration and improving the neonate's ability to breathe independently.

Choice C rationale

Betamethasone does not halt cervical dilation. Cervical dilation is primarily influenced by uterine contractions and the presenting fetal part. Medications like tocolytics, such as terbutaline or magnesium sulfate, are used to inhibit uterine contractions in preterm labor.

Choice D rationale

Betamethasone is not used to stop preterm labor contractions. Its primary purpose is to enhance fetal lung maturation. Tocolytic medications are the class of drugs used to attempt to delay or stop preterm labor contractions, allowing time for corticosteroids to be administered.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the different signs of pregnancy with a client who is in her first trimester.Which of the following symptoms should the nurse classify as a positive sign of pregnancy?

Correct Answer is C

Explanation

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor.The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication.The nurse should provide which of the following explanations?

Correct Answer is B

Explanation

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For each medication below, click to select the appropriate nursing action. (Each category can have zero or more response options selected)