A woman gave birth to a 7-lb, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate after birth period, the most serious consequence likely to occur from bladder distention is:
Excessive uterine bleeding
urinary tract infection
ruptured bladder
bladder wall atony
The Correct Answer is A
A. Excessive uterine bleeding:
Bladder distention can displace the uterus to the right and elevate it above the umbilicus, interfering with uterine contraction. This displacement prevents the uterus from contracting effectively, which can lead to excessive uterine bleeding, a serious complication. When the uterus does not contract properly, it may not effectively compress the blood vessels, increasing the risk of hemorrhage. Immediate attention to bladder distention is crucial to prevent this potentially life-threatening issue.
B. Urinary tract infection:
While urinary tract infections (UTIs) can occur in the postpartum period, especially if the bladder is not emptied completely, they are not the most immediate or serious consequence of bladder distention. The priority is to address the distended bladder to prevent complications like excessive bleeding. A UTI would be a concern later, but it would not be the most acute risk following delivery.
C. Ruptured bladder:
A ruptured bladder is a rare and severe complication but is not the most likely consequence of bladder distention in the immediate postpartum period. Bladder rupture typically occurs due to significant trauma or extreme distention, which is not common in this situation. The more immediate concern is uterine atony and hemorrhage due to displaced uterine tone from bladder distention.
D. Bladder wall atony:
Bladder wall atony could result from severe bladder distention, causing difficulty in voiding. However, this is not the most serious consequence immediately after birth. Bladder distention typically results in impaired uterine contraction, which causes bleeding rather than atony of the bladder wall itself. Addressing bladder distention will help prevent complications such as hemorrhage rather than focusing on bladder atony initially.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A) Clear fluids from airway:
Immediately clearing the infant's airway is one of the first steps in stabilizing the newborn after birth. This ensures the infant can breathe freely, reducing the risk of aspiration or airway obstruction. Suctioning the mouth and nose with a bulb syringe or suction catheter is the usual practice, especially if there are visible fluids or secretions. This intervention is critical for ensuring the infant's respiratory function.
B) Immediately assess and bathe baby:
While assessing the newborn is vital, it is not the immediate priority. The first step in stabilization is ensuring the newborn’s airway is clear, followed by efforts to prevent heat loss. Bathing should be delayed until after the baby is stable, and drying the baby thoroughly should be done as the first action to prevent hypothermia.
C) Dry infant thoroughly:
Drying the newborn thoroughly after birth is essential for preventing heat loss. Wet skin can quickly lead to hypothermia, and drying helps maintain the infant's body temperature. This intervention is vital for stabilizing the newborn and ensuring thermoregulation in the first moments of life.
D) Place baby skin to skin:
Skin-to-skin contact is a fundamental practice immediately after birth. It promotes bonding, helps regulate the infant's temperature, supports successful breastfeeding initiation, and stabilizes vital signs like heart rate and blood sugar levels. The mother’s body heat helps the baby maintain a normal temperature, which is especially important right after birth.
E) Give erythromycin ointment in baby’s eyes:
While applying erythromycin ointment to the baby’s eyes is a standard practice to prevent neonatal conjunctivitis (especially from gonorrhea or chlamydia), it is not a priority for immediate stabilization. This step is typically performed later, after the newborn is stable, and thermoregulation is addressed. The primary focus should be on airway clearance, drying, and promoting skin-to-skin contact first.
Correct Answer is A
Explanation
A) Prolactin:
Prolactin is the primary hormone responsible for stimulating milk production in the postpartum period. In breastfeeding mothers, prolactin levels remain elevated, especially during the first few weeks after delivery, to support lactation. This hormone is released in response to suckling and is essential for maintaining a steady milk supply. Elevated prolactin levels help establish and maintain breastfeeding during the early postpartum period, even as other pregnancy-related hormones begin to decline.
B) Estrogen:
Estrogen levels drop sharply after childbirth, as the placenta is no longer present to produce this hormone. The decline in estrogen is one of the factors that helps initiate lactation. While estrogen rises later during the postpartum period as the body returns to its non-pregnant state, it is not elevated during the immediate postpartum period in breastfeeding women.
C) Progesterone:
Similar to estrogen, progesterone levels fall quickly after delivery. Progesterone is involved in maintaining pregnancy, and its levels decrease significantly once the placenta is delivered. A reduction in progesterone is one of the hormonal changes that triggers the onset of lactation. It does not remain elevated in the immediate postpartum period.
D) Human placental lactogen (hPL):
hPL is produced by the placenta during pregnancy to support fetal growth and prepare the breasts for lactation. However, after delivery, hPL levels decline rapidly because the placenta is expelled. It is not elevated in the immediate postpartum period.
E) Relaxin:
Relaxin is a hormone that helps to soften the cervix and relax the ligaments in preparation for childbirth. Its levels are elevated during pregnancy and drop significantly after delivery. It does not remain elevated in the postpartum period, particularly in breastfeeding women.
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