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 D
Explanation
Choice A rationale
Uterine contractions every 15 minutes are characteristic of the latent phase of labor, not the active phase. In the active phase, contractions typically become stronger, more frequent, and more regular, occurring every 2 to 5 minutes, signifying progressive cervical dilation.
Choice B rationale
A fetal heart rate (FHR) baseline of 166/min with minimal variability is concerning. While a baseline up to 160/min is generally normal, 166/min is slightly elevated, and minimal variability (5 bpm or less) can indicate fetal hypoxia or acidosis, necessitating further assessment and intervention. Normal FHR baseline is 110-160 bpm.
Choice C rationale
Late decelerations in FHR are non-reassuring findings indicative of uteroplacental insufficiency, meaning inadequate oxygen transfer to the fetus. These decelerations suggest potential fetal distress and require immediate intervention and reporting to the provider, not an expected finding in active labor.
Choice D rationale
Contraction duration of 75 seconds is an expected finding in the active phase of labor. During this phase, contractions typically last 45 to 90 seconds. This duration contributes to effective cervical effacement and dilation, signifying adequate uterine activity for labor progression.
Correct Answer is A
Explanation
Choice A rationale
Terbutaline is a beta-adrenergic agonist that can cause significant cardiovascular side effects, including tachycardia. A heart rate of 132/min is significantly elevated above the normal range (60-100/min) and indicates a potentially dangerous adverse effect, increasing myocardial oxygen demand and risk of cardiac complications.
Choice B rationale
Headache is a common side effect of terbutaline due to its vasodilatory effects. While uncomfortable, it is generally not life-threatening and is considered less urgent than significant cardiac or respiratory compromise. Management often involves supportive care and pain relief.
Choice C rationale
Nasal congestion is a less common and generally benign side effect of terbutaline. It is typically related to generalized vasodilation and does not pose a significant threat to maternal or fetal well-being, thus not being the priority for immediate reporting.
Choice D rationale
Tremors are a common and expected side effect of terbutaline due to its beta-agonist activity on skeletal muscle. While bothersome, they are typically self-limiting and do not indicate a severe adverse reaction requiring immediate reporting unless they are excessively severe or debilitating.
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