A nurse is reviewing the medical record of a client who gave birth 2 hours ago. Which of the following findings increases the client’s risk for postpartum hemorrhage?
Boggy uterus.
Moderate lochia rubra.
First-degree perineal laceration.
Hypotension.
The Correct Answer is A
Choice A rationale
A boggy uterus indicates uterine atony, a leading cause of postpartum hemorrhage, as the uterus fails to contract effectively to compress blood vessels.
Choice B rationale
Moderate lochia rubra is expected postpartum vaginal bleeding, representing normal shedding of the uterine lining, not specifically indicating hemorrhage risk.
Choice C rationale
A first-degree perineal laceration is a minor tear that does not significantly increase the risk for postpartum hemorrhage as it usually involves limited bleeding.
Choice D rationale
Hypotension alone does not increase the risk for postpartum hemorrhage; however, it could be a result of ongoing hemorrhage rather than a cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Blood glucose level changes are unrelated to hyperbilirubinemia and phototherapy, which specifically target bilirubin metabolism in the newborn's liver and skin.
Choice B rationale
A decrease in transcutaneous bilirubin (TcB) levels shows effective phototherapy, as it converts bilirubin into water-soluble isomers that can be excreted.
Choice C rationale
Skin color changes from yellow to normal indicate reduced bilirubin levels, but the most accurate measure of phototherapy efficacy is the decrease in TcB levels.
Choice D rationale
Weight gain is not an indicator of effective phototherapy; it reflects overall nutrition and hydration status rather than bilirubin metabolism and excretion.
Correct Answer is C
Explanation
Choice A rationale
Delusions indicate severe psychiatric conditions like postpartum psychosis, not depression. Depression involves low mood, energy, and interest, without detachment from reality. Delusions reflect loss of reality testing, requiring different interventions. Common in severe psychoses like schizophrenia.
Choice B rationale
Euphoria indicates abnormally elevated mood, seen in manic episodes of bipolar disorder, not depression. Depression involves sadness, hopelessness, and low energy. Euphoria's excessive positivity contrasts with depressive symptoms, including impaired functioning and behavior regulation.
Choice C rationale
Flat affect signifies reduced emotional expression, common in depression. Depressed individuals exhibit lack of response to pleasurable activities, social withdrawal, and emotional blunting. This impairment in emotional expressiveness reflects major depressive disorder.
Choice D rationale
Insomnia, common in depression, affects sleep patterns, causing difficulty initiating or maintaining sleep. It contributes to fatigue, cognitive impairment, and mood disturbances. Insomnia reflects dysregulated sleep-wake cycles in depression, impacting daily functioning.
Choice E rationale
Fatigue is frequent in depression, marked by persistent tiredness despite rest. It stems from sleep disturbances, low energy, and anhedonia. Fatigue affects concentration, motivation, and physical activity, manifesting as psychomotor retardation in depression.
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