A nurse is caring for a client who is 36 hr postpartum.
After reviewing the information in the client's medical record, which of the following complications pose a greater risk for the client?
The complication that poses the greatest risk for the client is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Rationale for correct choices:
• Hemorrhage: The client demonstrates a boggy fundus that requires repeated massage to maintain firmness, a midline fundus with heavy lochia containing small clots, and increasing heart rate, all classic signs of postpartum hemorrhage. These findings indicate the uterus is not contracting effectively, placing the client at risk for excessive blood loss.
• Amount of lochia: The moderate to heavy lochia rubra with clots indicates ongoing uterine bleeding. Monitoring the amount and characteristics of lochia is critical for early recognition of hemorrhage.
Rationale for incorrect choices:
• Mastitis: The client’s breasts are soft, warm, and only mildly tender, with no signs of infection (redness, localized heat, or systemic symptoms), making mastitis unlikely.
• Endometritis: The client has a mildly elevated temperature but no significant fever, foul-smelling lochia, or severe uterine tenderness, so endometritis is less likely at this time.
• Temperature: While slightly elevated, the temperature is not high enough to indicate infection, and it does not correlate with the immediate risk of hemorrhage.
• Breast findings: The breast assessment shows normal postpartum changes without infection, making this less relevant to the acute risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Decrease in amount of lochia and passage of clots is incorrect because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and does not affect uterine bleeding or the passage of lochia. Changes in lochia are related to normal postpartum involution of the uterus and not pain medication.
B. Decrease in milk production is incorrect because the client is not breastfeeding, and ibuprofen does not suppress milk production. Milk production is influenced by lactation hormones such as prolactin and oxytocin.
C. Decrease in swelling in the extremities is incorrect because while NSAIDs can reduce inflammation, mild postpartum edema is generally physiologic and not significantly impacted by a single dose of ibuprofen. This outcome is not the primary therapeutic goal in this context.
D. Decrease in discomfort is correct because ibuprofen is administered to relieve postpartum pain, including uterine cramping, perineal discomfort, or musculoskeletal soreness after vaginal birth. Pain relief is the intended effect of the medication, and the nurse should evaluate the client’s reported pain level to determine if the desired outcome has been achieved.
Correct Answer is C
Explanation
Rationale:
A. One artery and one vein is incorrect because a normal umbilical cord contains three vessels, not two. A cord with a single artery and one vein indicates a condition known as a single umbilical artery (SUA). SUA is associated with an increased risk of congenital anomalies such as renal malformations, cardiac defects, and chromosomal abnormalities. Therefore, while it can occur, it is not the expected or normal finding during a routine assessment after delivery.
B. Two veins and one artery is incorrect because fetal circulation includes only one umbilical vein. The umbilical vein is responsible for transporting oxygenated blood from the placenta to the fetus. Having two veins is not part of normal development and would represent a vascular abnormality rather than a normal anatomical structure.
C. Two arteries and one vein is correct because this is the normal structure of the umbilical cord. The two umbilical arteries carry deoxygenated blood and metabolic waste from the fetus to the placenta. The single umbilical vein carries oxygenated, nutrient-rich blood from the placenta to the fetus, entering fetal circulation through the liver and the ductus venosus. This three-vessel configuration indicates normal fetal development and is what the nurse should expect to observe upon examining the cord after placental delivery.
D. Two arteries and two veins is incorrect because a four-vessel umbilical cord is not physiologically normal. This would indicate a rare congenital anomaly and is not the expected finding during a routine postpartum cord assessment.
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