Exhibits
The nurse is reviewing the clients’ chart. Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage
History and Physical A 36-year-old client who is gravida 5 para 5 (GSP5) transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine just prior to delivery. Her spouse was at the bedside for delivery and appeared supportive. Blood type A+. Estimated blood loss was 600 mL after delivery.
Nurses’ Notes Received GSP5 client 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was assisted to the bathroom where she voided 150 mL clear yellow urine. Lochia rubra moderate with small clots, no foul odor noted. Fundus firm at umbilicus. Episiotomy edges well approximated, no redness, edema, drainage, or ecchymosis. No pain, redness or swelling in calves. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18 gauge peripheral IV in the left forearm at 125 mL/hr, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
gravida 5 para 5
delivery of a 9 lb 1 oz (4.1 kg) female
labor for 25 hours and forceps were used to assist with the delivery
client had a 4th degree laceration
Estimated blood loss was 600 mL after delivery
Lochia rubra moderate with small clots
Episiotomy edges well approximated
A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing
The IV is patent, without redness or swelling
given an epidural for anesthesia that was effective
vital signs were stable
The Correct Answer is ["A","B","C","D","E","F"]
Based on the client’s history and physical, the following areas increase the risk for postpartum hemorrhage:
- Gravida 5 Para 5 (G5P5): Multiparity (having given birth 5 times) can increase the risk of postpartum hemorrhage due to uterine atony (lack of muscle tone) resulting from repeated stretching of the uterus.
- Delivery of a 9 lb 1 oz (4.1 kg) baby: Macrosomia (large baby) can overstretch the uterus, increasing the risk of uterine atony and postpartum hemorrhage.
- Labor for 25 hours and use of forceps for delivery: Prolonged labor and instrumental delivery can lead to uterine fatigue and atony, increasing the risk of postpartum hemorrhage.
- 4th degree laceration: Severe lacerations can lead to significant blood loss.
- Estimated blood loss was 600 mL after delivery: This is a significant amount of blood loss and could indicate a risk for further hemorrhage.
- Lochia rubra moderate with small clots: This could indicate ongoing blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A blood pressure of 100/60 mm Hg is not typically considered a risk for patients receiving eptifibatide. While eptifibatide can cause hypotension, a blood pressure of 100/60 mm Hg is within normal limits.
Choice B rationale
The presence of hematemesis, or vomiting blood, poses the greatest risk to the patient. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that prevents platelets from clumping together by blocking the action of certain proteins. This can increase the risk of bleeding, including gastrointestinal bleeding, which could manifest as hematemesis.
Choice C rationale
Incontinence with blood in the urine could indicate a urinary tract infection or other urinary system issue, but it is not typically associated with the use of eptifibatide.
Choice D rationale
Unresponsiveness to painful stimuli is a serious symptom that could indicate a number of issues, including neurological damage or severe illness. However, it is not typically associated with the use of eptifibatide.
Correct Answer is ["D","E","F","G"]
Explanation
Based on the provided information, the following aspects of the assessment require urgent attention:
- The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
- The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
- The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
- The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.
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