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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

The human body possesses compensatory mechanisms, such as sympathetic nervous system activation leading to vasoconstriction and increased heart rate, that can maintain vital organ perfusion despite significant blood loss. These mechanisms can mask overt signs of shock, such as hypotension, until approximately 20-25% of the total blood volume (around 1000-1250 mL in an average adult) has been acutely lost. This delay in visible manifestations can be critical in situations like postpartum hemorrhage, where rapid blood loss can occur.

Choice B rationale

Hemorrhagic shock typically leads to a state of metabolic acidosis, not an increase in serum pH. This occurs due to inadequate tissue perfusion, resulting in anaerobic metabolism and the accumulation of lactic acid. The reduced oxygen delivery forces cells to switch from efficient aerobic respiration to less efficient anaerobic glycolysis, producing lactate as a byproduct, which lowers the blood pH. A normal serum pH range is 7.35 to 7.45.

Choice C rationale

While urine output is a valuable indicator of renal perfusion and overall circulatory status, it is not the most accurate or immediate indicator of *overall* organ perfusion. Other parameters like mental status, skin perfusion (capillary refill), and arterial blood pressure (MAP) provide more global and rapid assessments of tissue oxygenation. Urine output primarily reflects renal blood flow, which can be maintained by compensatory mechanisms even when other organs are hypoperfused. Normal urine output is generally considered to be 0.5 to 1 mL/kg/hr.

Choice D rationale

The standard resuscitation guideline for hemorrhagic shock is to administer 3 mL of isotonic crystalloid solution, such as lactated Ringer's, for every 1 mL of estimated blood loss. This 3: ratio accounts for the rapid redistribution of crystalloids from the intravascular space to the interstitial space, meaning that only about one-third remains within the vascular compartment to expand circulating blood volume effectively.

A. A hematoma. B. Retained placental fragments. C. A laceration. D. Ecchymosis.

Correct Answer is A

Explanation

Choice A rationale

A perineal hematoma is a collection of blood in the connective tissue beneath the skin, often caused by trauma during childbirth. The reported findings of increasing perineal pain, pressure, purplish discoloration, and swelling are classic signs. The purplish hue indicates extravasated blood, and the swelling reflects the accumulation of fluid, which can exert significant pressure on surrounding tissues, leading to severe discomfort and a palpable mass.

Choice B rationale

Retained placental fragments typically manifest as persistent or excessive postpartum bleeding, often bright red, and can lead to uterine subinvolution and infection. While pain might be present due to uterine contractions, it would not typically present as a localized, purplish, swollen area on the perineum. This finding is not consistent with the pathophysiology of retained placental fragments, which primarily affects the uterus.

Choice C rationale

A laceration is a tear in the soft tissues of the perineum or vagina, resulting in bright red bleeding, pain, and sometimes a visible opening. While pain is present, a laceration would not typically present with a 4 cm purplish discoloration and significant swelling without active, bright red bleeding from the tear site itself. The described findings are more indicative of internal bleeding and tissue accumulation rather than an open wound.

Choice D rationale

Ecchymosis is a bruise, characterized by superficial extravasation of blood into the skin or mucous membranes, resulting in a purplish discoloration. While the purplish discoloration is consistent, ecchymosis alone typically does not involve the significant palpable swelling and increasing pressure described. The extent of swelling and pressure points to a deeper collection of blood, distinguishing it from simple superficial bruising.

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Naxlex Comprehensive Predictor Exams

A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect?

A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?

A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. Complete the following sentence by using the list of options. The nurse should identify that the client is at the greatest risk for _______ due to ________.

A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include?

A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?