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 C

Explanation

Choice A rationale

Patterned breathing techniques involve conscious control of respiratory rate and depth, which can redirect attention and promote relaxation. This cognitive distraction reduces the perception of pain by engaging higher cortical centers, thus modulating pain signals transmitted via the spinothalamic tracts. However, it does not directly address the localized pressure associated with back labor.

Choice B rationale

Effleurage involves light, circular stroking of the abdomen. This gentle cutaneous stimulation activates large-diameter afferent nerve fibers, which, according to the gate control theory of pain, can inhibit the transmission of noxious stimuli by smaller-diameter fibers in the spinal cord. While soothing, it may not provide sufficient counter-pressure for intense back labor.

Choice C rationale

Sacral counterpressure involves applying firm, sustained pressure to the sacrum. This technique directly opposes the pressure exerted by the fetal occiput against the sacral nerves during back labor. The deep pressure stimulates mechanoreceptors, which can significantly reduce the perception of pain through afferent inhibition and potentially alter the biomechanics of fetal descent.

Choice D rationale

Guided imagery involves directing the client to focus on pleasant mental images to divert attention from pain. This cognitive behavioral strategy can activate descending inhibitory pathways from the brainstem, releasing endogenous opioids and serotonin, thereby modulating pain perception. However, it may not be as effective for the specific, intense pressure of back labor.

A. "Give your newborn only to staff members you recognize.”. B. "Remove your newborn's microchip identification band after you have arrived home.”. C. "Personally carry your newborn to the nursery if you need assistance.”. D. "Bring your newborn in the bassinet into the bathroom with you.”.

Correct Answer is D

Explanation

Choice A rationale

Relying solely on facial recognition of staff members is an insufficient and potentially dangerous security measure. Hospital staff members can change shifts, and imposters might attempt to abduct newborns. Robust security protocols, such as mandatory identification badges and alarm systems on infant security tags, are designed to prevent unauthorized individuals from leaving the unit with an infant, providing a more reliable defense against abduction.

Choice B rationale

The instruction to remove a newborn's microchip identification band after arriving home is inaccurate and potentially misleading. Hospitals typically use infant security tags or bands that are removed by staff upon discharge, not by the parents at home. These bands are crucial for preventing abductions within the facility by triggering alarms if an infant is taken beyond designated boundaries.

Choice C rationale

Personally carrying a newborn to the nursery, especially without supervision or adherence to facility protocols, increases the risk of abduction. Hospitals often require staff to transport infants in bassinets or cribs, typically with two staff members present, to minimize opportunities for unauthorized individuals to gain access to or abduct a newborn. This procedure enhances infant safety significantly.

Choice D rationale

Bringing the newborn in the bassinet into the bathroom with the mother maintains constant direct observation and reduces the risk of abduction. This strategy minimizes the time the infant is left unattended, preventing opportunities for an abductor to seize the child. Maintaining proximity and direct line of sight is a fundamental principle of infant security in a hospital environment.

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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 ________.

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Correct Answer is C

Explanation

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Correct Answer is D

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
.