A nurse is caring for a female client, 32 years old, in the postpartum unit following an emergency cesarean birth.
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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.
Choice B rationale
Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.
Choice C rationale
An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.
Choice D rationale
Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause variable decelerations on fetal monitoring.
Choice B rationale
Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates or effaces.
Choice C rationale
A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in placenta previa.
Choice D rationale
Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use or other uterine stimulants.
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