Day 1, 2350:
Client admitted to the postpartum unit.
Fundus firm at umbilicus.
Moderate amount of lochia rubra noted.
No concerns voiced by client.
Day 2,
0600:
Client resting in bed.
Reports pain as 5 on a scale of 0 to 10. Declines pain medication.
Fundus firm at umbilicus.
Moderate amount of lochia rubra noted.
Perineal pad changed.
Client assisted to the bathroom, voided 50 mL of urine.
Client performed incentive spirometer exercises.
0700:
Called to bedside by client.
Client reports needing help changing perineal pad.
Perineal pad saturated.
Fundus boggy and 2 finger breaths above the umbilicus deviated to the right side.
Client reports pain as 3 on a scale of 0 to 10. Client reports urge to urinate.
Ambulated client to the bathroom.
Client reports straining to empty bladder.
Client voided 50 mL of bloody urine.
Perineal pad changed.
Provider notified.
0715:
Straight catheter inserted per routine prescription.
Urinary output 700 mL of pink-tinged urine in catheter returned.
Which of the following conditions is the client most likely experiencing?
Postpartum hemorrhage.
Postpartum infection.
Endometritis.
Urinary tract infection.
Uterine inversion.
The Correct Answer is A
Choice A rationale
The client's fundus is boggy and elevated above the umbilicus, deviating to the right, which indicates uterine atony. This, coupled with the saturated perineal pad and voiding of only 50 mL of urine initially, followed by 700 mL of pink-tinged urine after catheterization, suggests significant blood loss. These findings are classic signs of postpartum hemorrhage, which is often caused by uterine atony preventing effective uterine contraction and vessel compression. Normal postpartum fundal height should decrease daily.
Choice B rationale
Postpartum infection, such as puerperal sepsis, typically presents with fever, chills, uterine tenderness, and foul-smelling lochia. While the client is experiencing discomfort, there is no mention of fever or purulent discharge. The primary signs observed relate to excessive bleeding and uterine displacement, not infectious processes. A normal temperature range is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice C rationale
Endometritis is an infection of the uterine lining, often occurring postpartum. Symptoms include fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia. The client's symptoms of a boggy fundus, heavy bleeding, and fundal deviation are more indicative of a bleeding issue rather than an infection confined to the endometrium. White blood cell count would typically be elevated in infection, with a normal range being 4,500 to 11,000 cells/mm³.
Choice D rationale
A urinary tract infection (UTI) is characterized by dysuria, urgency, frequency, and sometimes hematuria. While the client reports an urge to urinate and voided a small amount, the primary and more concerning findings are related to the uterine status and excessive bleeding, which are not typical signs of a UTI. A urine culture would show bacterial growth in a UTI, with a normal urinalysis showing no or few bacteria.
Choice E rationale
Uterine inversion is a rare but severe complication where the uterus turns inside out, often presenting with sudden, severe pain, vaginal hemorrhage, and a mass protruding from the vagina. While hemorrhage is present, the description of the fundus being boggy and 2 finger breaths above the umbilicus, rather than inverted or prolapsed, makes uterine inversion less likely. The primary issue is uterine atony leading to blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Complete the sentence: The nurse should massage the uterus and prepare to administer oxytocin.
Rationale for correct answers:
Uterine atony is the most common cause of postpartum hemorrhage (PPH), indicated by a boggy uterus and heavy bleeding with clots. Uterine massage stimulates uterine contractions, promoting involution and reducing bleeding. Oxytocin is a first-line uterotonic agent that increases uterine tone by stimulating smooth muscle contraction, helping to control hemorrhage. Normal hemoglobin is 11-16 g/dL; the client’s drop to 9.4 g/dL and hematocrit decrease to 27% (normal 33%-47%) indicate blood loss requiring prompt intervention.
Rationale for incorrect Response 1 options:
Inserting an indwelling urinary catheter is unnecessary here because the client emptied her bladder without difficulty, and urinary retention is not evident. Oxygen administration by nasal cannula is not indicated since the client’s respiratory rate is normal and there is no sign of hypoxia. Immediate oxygen is reserved for hypoxic or unstable patients.
Rationale for incorrect Response 2 options:
Administering oxygen by nasal cannula is not needed without hypoxia signs. Initiating a 1000 mL sodium chloride bolus might be considered later if hypovolemia or hypotension worsens but is not the immediate priority. Inserting an indwelling urinary catheter is not indicated as the bladder is emptying normally, and unnecessary catheterization risks infection.
Take-home points:
- Postpartum hemorrhage is primarily caused by uterine atony, presenting with a boggy uterus and heavy bleeding.
- Prompt uterine massage and administration of oxytocin are critical first-line interventions to control bleeding.
- Laboratory values such as hemoglobin and hematocrit help assess blood loss severity and guide management.
- Differentiation from other causes of bleeding (e.g., retained placenta, lacerations) requires assessment but initial treatment focuses on uterine tone restoration.
Correct Answer is D
Explanation
Choice A rationale
Wound infection following circumcision typically presents with signs such as erythema (redness), localized warmth, purulent drainage, and swelling, often accompanied by fever. Yellow exudate alone, without these other inflammatory indicators, does not align with the typical presentation of a bacterial infection.
Choice B rationale
Ulceration would manifest as an open sore or a break in the skin integrity, often with raw, exposed tissue. The yellow exudate covering the glans, if it represents a healing process, is a protective layer and not indicative of tissue breakdown or an open ulcer.
Choice C rationale
Exposure to urine does not typically result in a uniform yellow exudate covering the glans. While prolonged urine exposure can lead to skin irritation or maceration, the described finding is a distinct physiological response associated with tissue repair rather than simple urinary contact.
Choice D rationale
The formation of a yellow exudate or "scab" on the glans penis is a normal physiological response during the healing process after circumcision. This fibrinogen-rich layer acts as a protective barrier, preventing infection and facilitating re-epithelialization of the wound, and it typically resolves within 7-10 days.
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