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

Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing
_
and
.

Answer and Explanation

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

Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing postpartum hemorrhage and urinary tract infection.

Rationale for correct answers
Postpartum hemorrhage risk is indicated by a boggy fundus located 2 fingerbreadths above the umbilicus and deviated to the right, signifying uterine atony and bladder distention. Uterine atony causes inadequate contraction, increasing bleeding risk. Normal fundal position is firm, midline, at or below the umbilicus. The client’s saturated perineal pad confirms excessive bleeding. Urinary tract infection risk is suggested by urinary retention signs (urge to urinate but only voiding 50 mL) and straining, increasing bacterial colonization risk. Blood-tinged urine further supports urinary tract irritation or infection. Normal urine output in adults is approximately 0.5 mL/kg/hr; this client’s low output suggests retention.

Rationale for incorrect answers
Postpartum infection (B) and endometritis (C) are possible but less immediately likely; WBC is normal at 7,500/mm³ and temperature is only mildly elevated (37.7°C). Uterine inversion (D) is a rare, acute emergency with a prolapsed uterus, not described here. Endometritis (B) typically presents with fever, uterine tenderness, and elevated WBC, absent here.

Rationale for incorrect answers
Postpartum infection (A) and endometritis (B) again are unlikely given stable WBC and low-grade temperature. Uterine inversion (D) does not correlate with the clinical presentation of a boggy, displaced fundus and urinary retention. The urinary tract infection (C) is most consistent with symptoms of retention, pain, and bloody urine.

Take home points

Boggy, displaced fundus with heavy bleeding signals uterine atony and postpartum hemorrhage risk.
Urinary retention increases risk for urinary tract infection post-cesarean birth.
Mild temperature elevation and normal WBC do not confirm infection but warrant monitoring.
Differentiating uterine atony from uterine inversion and infection is critical for timely intervention.

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Correct Answer is B

Explanation

Choice A rationale

A positive pregnancy test detects the presence of human chorionic gonadotropin (hCG) in urine or blood. While highly suggestive, it is classified as a probable sign because certain conditions other than pregnancy can elevate hCG levels, although these are rare, making it not definitively diagnostic.

Choice B rationale

Amenorrhea, the cessation of menstruation, is a common early indicator of pregnancy due to hormonal changes, specifically rising progesterone levels that inhibit follicular development and uterine shedding. However, various factors unrelated to pregnancy, such as stress or hormonal imbalances, can also cause amenorrhea, categorizing it as a presumptive sign.

Choice C rationale

Fetal heart sounds, when auscultated, are a definitive sign of pregnancy because they directly confirm the presence of a viable fetus. This auditory confirmation is unambiguous and cannot be attributed to any other condition, making it a positive sign of pregnancy.

Choice D rationale

Chadwick sign refers to the bluish-purple discoloration of the cervix, vagina, and labia due to increased vascularity and blood flow, typically observed around 6-8 weeks of gestation. While highly indicative of pregnancy, it is considered a probable sign because other conditions can also cause pelvic congestion, although less commonly.

A. Manifestations of shock might not appear until a client loses 20% of their blood volume. B. Hemorrhagic shock will cause an increase in a client's serum pH level. C. The most accurate indication of organ perfusion is a client's urine output. D. An infusion of 1 mL of lactated Ringer's is given for each 1 mL of blood loss.

Correct Answer is A

Explanation

Choice A rationale

The human body possesses compensatory mechanisms, such as sympathetic nervous system activation leading to vasoconstriction and increased heart rate, that can maintain vital organ perfusion despite significant blood loss. These mechanisms can mask overt signs of shock, such as hypotension, until approximately 20-25% of the total blood volume (around 1000-1250 mL in an average adult) has been acutely lost. This delay in visible manifestations can be critical in situations like postpartum hemorrhage, where rapid blood loss can occur.

Choice B rationale

Hemorrhagic shock typically leads to a state of metabolic acidosis, not an increase in serum pH. This occurs due to inadequate tissue perfusion, resulting in anaerobic metabolism and the accumulation of lactic acid. The reduced oxygen delivery forces cells to switch from efficient aerobic respiration to less efficient anaerobic glycolysis, producing lactate as a byproduct, which lowers the blood pH. A normal serum pH range is 7.35 to 7.45.

Choice C rationale

While urine output is a valuable indicator of renal perfusion and overall circulatory status, it is not the most accurate or immediate indicator of *overall* organ perfusion. Other parameters like mental status, skin perfusion (capillary refill), and arterial blood pressure (MAP) provide more global and rapid assessments of tissue oxygenation. Urine output primarily reflects renal blood flow, which can be maintained by compensatory mechanisms even when other organs are hypoperfused. Normal urine output is generally considered to be 0.5 to 1 mL/kg/hr.

Choice D rationale

The standard resuscitation guideline for hemorrhagic shock is to administer 3 mL of isotonic crystalloid solution, such as lactated Ringer's, for every 1 mL of estimated blood loss. This 3: ratio accounts for the rapid redistribution of crystalloids from the intravascular space to the interstitial space, meaning that only about one-third remains within the vascular compartment to expand circulating blood volume effectively.

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A nurse is caring for a female client following an emergency cesarean birth in the postpartum unit. Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing _________ and ________.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

Correct Answer is A

Explanation

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

Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing
_
and
.