A nurse is caring for a 35-year-old female client who is immediately postpartum in the labor and delivery 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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Combination oral contraceptives are contraindicated for smokers over 35 due to an increased risk of cardiovascular events such as thromboembolism and myocardial infarction. While the client is younger, her smoking habit is still a significant risk factor, and oral contraceptives do not protect against sexually transmitted infections given her multiple partners.
Choice B rationale
Depo-Provera, an injectable progestin, can cause irregular bleeding and potential weight gain, which might not be ideal given the client's existing irregular menstrual cycles and menorrhagia. Furthermore, it does not offer protection against sexually transmitted infections.
Choice C rationale
Barrier methods such as female condoms, when used consistently and correctly, provide protection against both pregnancy and sexually transmitted infections, which is crucial given the client's multiple partners. While they require proper education and may have a higher failure rate than hormonal methods, they address the STI risk directly.
Choice D rationale
A contraceptive implant is a highly effective long-acting reversible contraceptive. However, it does not protect against sexually transmitted infections. Given the client's multiple partners, STI protection is a primary concern that the implant does not address. .
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Headache in a postpartum patient, especially if severe, persistent, or accompanied by visual disturbances or hypertension, can be a sign of serious conditions such as preeclampsia or postpartum eclampsia. These conditions require immediate medical attention due to the potential for significant maternal morbidity and mortality.
Choice B rationale
Gestational age is a historical data point related to the pregnancy and delivery. While important for understanding the newborn's potential risks and maturity, it is not a priority concern in the immediate postpartum period for the mother unless complications related to preterm or post-term delivery arise in the mother.
Choice C rationale
Heartburn, or pyrosis, is a common discomfort during pregnancy due to hormonal changes and pressure on the stomach. While it can persist postpartum, it is generally not a priority concern unless it is severe, atypical, or associated with other concerning symptoms like chest pain, which could indicate a different underlying issue.
Choice D rationale
Abnormal liver function tests in the postpartum period can indicate serious conditions such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count), a severe form of preeclampsia that can occur postpartum. These abnormalities require prompt investigation and management due to the potential for life-threatening complications. .
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