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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The American Academy of Pediatrics recommends that infants remain in a rear-facing car seat until they reach the maximum height or weight allowed by the car seat manufacturer, which often corresponds to approximately 2 years of age or older. This position provides superior protection for the infant's head, neck, and spine in the event of a frontal collision by distributing crash forces more effectively.
Choice B rationale
A five-point harness, not a four-point harness, is the standard and safest restraint system for infant and child car seats. The five points of attachment (shoulders, hips, and crotch) distribute crash forces across the strongest parts of the body, providing maximum protection and preventing ejection from the seat.
Choice C rationale
For a rear-facing car seat, the shoulder harness straps should be positioned at or *below* the baby's shoulders. This ensures that the straps are snug and correctly restrain the child, preventing upward movement and potential ejection during a collision. Placing them above the shoulders would not provide optimal restraint.
Choice D rationale
An infant car seat should be positioned at a 45-degree angle, not a 30-degree angle. This reclined position is crucial for maintaining an open airway for the infant, especially newborns who lack full head and neck control, and for preventing their head from falling forward, which could obstruct breathing.
Correct Answer is A
Explanation
Choice A rationale
Following an amniotomy, there is a direct communication between the uterine cavity and the vaginal canal, increasing the risk of ascending infection. Frequent monitoring of the client's temperature, typically every 2 hours, is essential to detect early signs of chorioamnionitis, a bacterial infection of the amniotic sac, which can lead to maternal and fetal complications.
Choice B rationale
Misoprostol is a prostaglandin E1 analog used for cervical ripening and induction of labor, not for post-amniotomy care. Its administration after amniotomy would not be appropriate for managing the immediate risks or discomfort associated with the procedure and could potentially cause excessive uterine contractions.
Choice C rationale
A biophysical profile (BPP) is an antenatal assessment of fetal well-being, typically performed to evaluate fetal oxygenation and central nervous system function. It is not an intervention performed during or immediately after an amniotomy, which is a procedure to rupture the amniotic membranes.
Choice D rationale
Effleurage is a light, rhythmic stroking of the abdomen used as a comfort measure during labor, often to distract from contractions. While it can be a helpful pain management technique, it is not a direct action specifically indicated for addressing the physiological consequences or risks associated with an amniotomy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.