A nurse is caring for a female client, 32 years old, in the postpartum unit following an emergency cesarean birth.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Based on the assessment findings, the nurse identifies that the client is at greatest risk for developing
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and
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Based on the assessment findings, the nurse identifies that the client is at greatest risk for developing:

Postpartum infection
Hemorrhage

Here's the

Postpartum infection: The client has a history of prolonged rupture of membranes and is experiencing a moderate amount of lochia rubra, both of which increase the risk of infection. Additionally, she reports feeling weak, fatigued, and has a temperature of 38.5°C (101.3°F), which are signs of a possible infection.
Hemorrhage: The moderate amount of lochia rubra and a boggy fundus above the umbilicus indicate that the client may be at risk for postpartum hemorrhage. The provider's prescription for administering oxytocin if needed also suggests a concern for uterine atony, which can lead to hemorrhage.

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Correct Answer is A

Explanation

Choice A rationale

Fetal heart rate (FHR) accelerations with fetal movement are a sign of a healthy and reactive nonstress test. This indicates that the fetus is well-oxygenated and there is no immediate distress.

Choice B rationale

Late decelerations of the FHR occur with contractions and are a concern for fetal hypoxia. This does not indicate a reactive nonstress test and instead suggests the need for further evaluation.

Choice C rationale

Variable decelerations are abrupt decreases in FHR and could indicate umbilical cord compression. This does not correlate with a reactive nonstress test.

Choice D rationale

FHR pattern with minimal variability can be a sign of fetal distress or compromised oxygenation. It is not indicative of a reactive nonstress test.

A. Check the client's temperature frequently following the procedure. B. Insert misoprostol rectally every 2 hours following the procedure. C. Obtain a biophysical profile during the procedure. D. Perform effleurage to the client's abdomen during the procedure.

Correct Answer is A

Explanation

Choice A rationale

Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early detection and management of any potential infections.

Choice B rationale

Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage, not for routine use post-amniotomy.

Choice C rationale

Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.

Choice D rationale

Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation.Which of the following findings indicates a reactive nonstress test?

Correct Answer is A

Explanation

A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.Which of the following statements should the charge nurse include during the discussion?

Correct Answer is A

Explanation

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