A nurse is caring for a client who has just delivered her second twin vaginally and notes that there is excessive bleeding from her vagina and that her uterus feels boggy on palpation.
The nurse should suspect which of the following complications?
Uterine atony
Uterine inversion
Uterine rupture
Uterine infection
The Correct Answer is A
The correct answer is choice A. Uterine atony.
Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage. A boggy uterus on palpation is a sign of uterine atony.
Choice B. Uterine inversion is wrong because it is a rare complication in which the uterus turns inside out and protrudes through the cervix. It usually causes severe pain, shock, and hemorrhage.
Choice C. Uterine rupture is wrong because it is a life-threatening emergency in which the uterus tears open along the scar line of a previous cesarean delivery or other uterine surgery. It usually causes severe abdominal pain, fetal distress, and maternal hypovolemic shock.
Choice D. Uterine infection is wrong because it is an inflammation of the endometrium (the lining of the uterus) caused by bacteria. It usually causes fever, foul-smelling lochia, and lower abdominal tenderness.
Normal ranges for postpartum bleeding are about 500 ml for vaginal delivery and 1000 ml for cesarean delivery. The uterus should feel firm and midline at or below the umbilicus after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choiceA.
The nurse should instruct the client to avoid lifting anything heavier than the newborn for 6 weeks.This is because lifting heavy objects can strain the abdominal muscles and the incision site, and increase the risk of bleeding and infection.
ChoiceBis wrong because the nurse should advise the client to wait at least 4 to 6 weeks before resuming sexual intercourse.This is to allow the incision to heal and prevent infection and discomfort.
ChoiceCis wrong because the nurse should not recommend ibuprofen for pain relief as it can interfere with blood clotting and increase bleeding.The nurse should suggest acetaminophen or a prescribed analgesic instead.
ChoiceDis wrong because the nurse should not tell the client to report any foul-smelling vaginal discharge to the provider.
The client should expect some vaginal discharge (lochia) for several weeks after a cesarean delivery, which may have a mild odor.However, the nurse should instruct the client to report signs of infection such as fever, chills, redness, swelling, or increased pain at the incision site.
Correct Answer is A
Explanation
The correct answer is choice A. “I will avoid squatting or sitting on the toilet after my water breaks.” This statement indicates that the patient understands how to prevent umbilical cord prolapse, which is a rare but serious complication that occurs when the umbilical cord slips out of the cervix before the baby during labor.This can cut off the baby’s blood and oxygen supply and require immediate delivery.
Choice B is wrong because drinking plenty of fluids does not affect the amniotic fluid level, which is determined by the placenta and the baby’s kidneys.Excessive amniotic fluid (polyhydramnios) can actually increase the risk of umbilical cord prolapse.
Choice C is wrong because monitoring the baby’s movements does not prevent umbilical cord prolapse, although it can help detect fetal distress if the cord is compressed.Decreased fetal movements can have other causes besides cord prolapse, such as fetal sleep cycle, maternal medication, or placental insufficiency.
Choice D is wrong because sleeping on the left side does not prevent umbilical cord prolapse, although it can improve blood flow to the baby and reduce the risk of supine hypotension syndrome.Umbilical cord prolapse can occur regardless of the maternal position.
Normal ranges for amniotic fluid index (AFI) are 5 to 25 cm.Normal ranges for fetal heart rate (FHR) are 110 to 160 beats per minute (bpm).
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