A nurse is caring for a patient who is 36 hours postpartum.
After reviewing the information in the patient’s medical record, which of the following complications pose a greater
risk for the patient?
Perineal pad clots
Pelvic pain
Boggy uterus
Breast Engorgement
The Correct Answer is C
Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s true that a newborn’s stools will transition in color, it typically takes a few days longer than one or two. Initially, the stools are a greenish-black color known as meconium. Over the next few days, as the baby begins digesting breast milk or formula, the stools will gradually transition to a yellow color.
Choice B rationale
This statement is correct. After childbirth, the breasts undergo a process known as engorgement when they start to produce milk. This can cause the breasts to become harder, warmer, and more tender. This is a normal part of the postpartum period and is a sign that the body is preparing to feed the baby.
Choice C rationale
While it’s true that abdominal discomfort generally decreases over time after childbirth, it’s important to note that the rate of decrease can vary greatly among individuals. Factors such as the type of delivery (vaginal or cesarean), individual pain tolerance, and the presence of any complications can all influence the rate of decrease in abdominal discomfort.
Choice D rationale
While it’s true that many women do feel more energetic as their bodies recover from childbirth, this is not always the case. Factors such as sleep deprivation, hormonal changes, and the physical demands of caring for a newborn can all contribute to feelings of fatigue and exhaustion. Therefore, while some women may feel more energetic, others may continue to feel tired for several weeks or even months after giving birth.
Correct Answer is A
Explanation
Choice A rationale
This is the correct answer. In infants of mothers with poorly controlled diabetes, hyperinsulinemia can lead to increased oxygen consumption and metabolic rate, which can contribute to the development of respiratory distress syndrome.
Choice B rationale
Increased blood viscosity is not the most likely cause of respiratory distress in a macrosomic newborn of a mother with poorly controlled diabetes.
Choice C rationale
A brachial plexus injury is a potential complication of delivery for macrosomic infants, but it is not a cause of respiratory distress syndrome.
Choice D rationale
Increased deposits of fat in the chest and shoulder areas can make delivery more difficult and can increase the risk of birth injuries, but they are not the most likely cause of respiratory distress syndrome in a macrosomic newborn of a mother with poorly controlled diabetes.
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