A nurse is caring for a woman who has just had a cesarean birth.
To monitor for potential hemorrhage, what should the recovery room nurse assess?
Assess the uterus for firmness every 15 minutes.
Monitor her urinary output.
Assess the abdominal dressings for drainage.
Maintain an intravenous infusion at 100 mL/hr.
The Correct Answer is A
Choice A rationale
The primary mechanism for preventing postpartum hemorrhage, which is a major risk following any birth including cesarean, is effective uterine contraction (involution). Postpartum hemorrhage is defined as blood loss greater than 1000 mL. Assessing the uterus for firmness (contraction) every 15 minutes in the immediate recovery phase confirms that the myometrial muscle fibers are constricting the uterine blood vessels at the placental site, which is the most critical intervention to prevent excessive bleeding.
Choice B rationale
Monitoring urinary output is essential for assessing renal perfusion and hydration status, and a decrease in output can be an indicator of hypovolemic shock secondary to hemorrhage, but it is not the primary direct assessment for the source of the hemorrhage. The nurse must first assess the fundus to prevent the hemorrhage itself. Normal urinary output is ≥ 30 mL/hr.
Choice C rationale
Assessing the abdominal dressings is necessary to monitor for incisional bleeding, which is a local complication. However, the most life-threatening source of hemorrhage after cesarean birth, like vaginal birth, remains at the placental implantation site inside the uterus. Therefore, the fundal assessment takes precedence over the dressing check for hemorrhage risk.
Choice D rationale
Maintaining a peripheral intravenous infusion (IV) is a standard measure to ensure intravascular access for fluid resuscitation or medication administration (e.g., oxytocin). While important for supportive care, maintaining a specified infusion rate of 100 mL/hr is a therapeutic action, not an assessment for hemorrhage. The primary assessment remains the firm contraction of the uterine muscle.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
At 48 hours (2 days) postpartum, the normal physiological process of uterine involution should have already progressed beyond the umbilicus. Immediately after birth, the fundus is firm, midline, and typically at the umbilicus (or 1-2 fingerbreadths below). A fundus remaining at the umbilicus at 48 hours could suggest subinvolution or retained products.
Choice B rationale
Uterine involution, the process of the uterus returning to its non-pregnant state, typically involves a descent of approximately 1 cm (one fingerbreadth) every 24 hours. Therefore, after 48 hours (2 days), the fundus is expected to be about two fingerbreadths (or ≈ 2 cm) below the level of the umbilicus in a healthy postpartum woman experiencing normal involution.
Choice C rationale
A fundus located two fingerbreadths above the umbilicus at 48 hours postpartum is an abnormal finding. This suggests that the uterus is larger than expected, potentially due to uterine atony (a lack of muscle tone) or the presence of a full bladder, which displaces the uterus superiorly and laterally, predisposing the client to postpartum hemorrhage.
Choice D rationale
While the fundus does descend, four fingerbreadths (about 4 cm) below the umbilicus is the typical location expected around the fourth day postpartum, not the second. This measurement indicates the expected daily rate of involution; therefore, a descent this low at 48 hours would be faster than the expected physiological rate of descent.
Correct Answer is C
Explanation
Choice A rationale
Confirming the mother's room number is a basic safety and logistical measure, but it does not provide definitive, legally verifiable identification to link the specific infant to the correct mother. The primary safeguard against infant abduction or accidental mix-up is the unique, unalterable identification system applied immediately after birth, which is the comparison of corresponding numbered bands, ensuring the identity match.
Choice B rationale
Asking the mother, "Is this your band number?", is an inappropriate leading question that could elicit an incorrect, affirmative response, compromising security. The nurse must independently verify the match between the numbered band on the infant and the corresponding numbered band on the mother (or a significant other), ensuring that the unique identifying codes are identical before transferring custody.
Choice C rationale
The comparison of the band number of the infant with that of the mother is the most critical and non-negotiable step for security. Identification bands, applied in the delivery room, bear matching, unique numbers and are the primary system of positive identification. This check ensures that the specific infant being transported is biologically and legally linked to the specific mother, thereby preventing accidental mix-ups or abductions.
Choice D rationale
Asking the mother to verbally identify herself (e.g., state her full name) helps confirm the identity of the person receiving the infant but is not sufficient for infant security. Verbal identification is easily compromised and does not verify the infant's identity. The essential security measure remains the visual and numerical comparison of the infant's and mother's matching identification band numbers.
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