A perinatal nurse is caring for a woman who delivered by cesarean section 1 hour ago. The nurse's assessment reveals the client is experiencing profuse lochial bleeding. What is the most likely cause for this bleeding?
Uterine inversion
Vaginal laceration
Uterine atony
Vaginal hematoma
The Correct Answer is C
A. Uterine inversion is a rare, life-threatening emergency in which the uterus turns inside out. It presents with sudden, severe abdominal pain, hemorrhage, shock, and the inability to palpate the uterine fundus abdominally. Although bleeding can be heavy, it is uncommon and not the most likely cause of profuse lochial bleeding 1 hour after a cesarean section.
B. Vaginal lacerations cause persistent bleeding despite a firm, well-contracted uterus and are more commonly associated with operative or traumatic vaginal deliveries. Since this client delivered by cesarean section, vaginal lacerations are less likely to be the source of heavy lochial bleeding.
C. Uterine atony is the most common cause of early postpartum hemorrhage, occurring within the first 24 hours after delivery. It results from failure of the uterus to contract and compress blood vessels at the placental site, leading to excessive lochial bleeding. Risk factors include prolonged labor, overdistended uterus, infection, and cesarean delivery.
D. Vaginal hematomas result from concealed bleeding into soft tissues and typically present with severe perineal or rectal pain, pressure, and signs of hypovolemia with minimal visible bleeding, making this an unlikely cause of profuse lochial bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Suggesting that further testing is needed implies that the score is abnormal or inconclusive. A BPP score of 8 out of 10 is generally considered normal, indicating that the fetus is well-oxygenated and not showing signs of compromise, so immediate further testing is not indicated.
B. While an obstetric specialist may review BPP results as part of routine care, the nurse should first provide accurate, reassuring information about the score. This response could cause unnecessary anxiety.
C. Immediate delivery by cesarean is not indicated for a BPP score of 8. Cesarean delivery is usually considered for scores of 4 or less, which indicate significant fetal compromise.
D. The test results are within normal limits is correct. A BPP evaluates fetal breathing movements, body movements, muscle tone, amniotic fluid volume, and nonstress test results, each scored 0–2. A total of 8–10 indicates a healthy fetus with no evidence of acute distress. This response reassures the client and accurately reflects the meaning of her BPP score.
Correct Answer is C
Explanation
A. Nalbuphine is an opioid agonist-antagonist used for maternal pain relief. It does not reverse opioid effects in the neonate and therefore cannot be used to counteract neonatal respiratory depression caused by butorphanol.
B. Fentanyl is a potent opioid analgesic, not a reversal agent. Administering fentanyl to a neonate would increase opioid effects, potentially worsening respiratory depression, rather than mitigating it.
C. Naloxone is an opioid antagonist that rapidly reverses the effects of opioids such as butorphanol, including respiratory depression, sedation, and decreased muscle tone in the neonate. It can be administered to the neonate immediately after birth if there are signs of opioid-induced depression, such as low Apgar score, poor respiratory effort, or decreased reflexes. The nurse should have naloxone readily available when opioids are administered near delivery.
D. Promethazine is an antihistamine with antiemetic and sedative properties. It has no effect on opioid-induced respiratory depression and is not appropriate for reversing butorphanol effects in the neonate.
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