The nurse is reviewing the client’s chart.
Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.
Client was middle aged and married.
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.
Client was middle aged
forceps were used to assist with the delivery
client had a 4th degree laceration
She was in labor for 25 hours
The Correct Answer is ["B","C","D"]
Choice A rationale
Age of the client is not a significant risk factor for postpartum hemorrhage. While age can influence overall health and pregnancy complications, it is not directly linked to an increased risk of postpartum hemorrhage. Therefore, the age of the client, in this case, does not increase the risk for postpartum hemorrhage.
Choice B rationale
The use of forceps during delivery can increase the risk of postpartum hemorrhage. Forceps delivery is an assisted delivery method which can cause trauma to the birth canal, leading to increased bleeding after delivery. In this case, the client had a forceps-assisted delivery, which could increase her risk for postpartum hemorrhage.
Choice C rationale
A 4th degree laceration is a severe tear that occurs during delivery, extending to the anal sphincter and rectal mucosa. This type of laceration can lead to significant blood loss and increase the risk of postpartum hemorrhage. In this case, the client had a 4th degree laceration, which increases her risk for postpartum hemorrhage.
Choice D rationale
A long labor duration can increase the risk of postpartum hemorrhage. Prolonged labor can lead to uterine atony, a condition where the uterus does not contract properly after delivery, leading to increased bleeding. In this case, the client was in labor for 25 hours, which could increase her risk for postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This is the most appropriate response because it emphasizes the importance of a healthcare provider's role in determining the best contraceptive method for an individual. It also respects the client's privacy and autonomy¹².
Choice B rationale
While it's important to understand a person's sexual activity when discussing contraception, asking for such details might make the client uncomfortable and could be seen as intrusive¹.
Choice C rationale
This response might be perceived as judgmental or patronizing. It's important to provide factual information and support without making assumptions about the client's readiness for a sexual relationship¹.
Choice D rationale
While barrier methods can be effective, they might not be the best choice for everyone. The best contraceptive method depends on a variety of factors, including the individual's health, lifestyle, and personal preferences¹². Therefore, it's best to consult with a healthcare provider¹².
Correct Answer is A
Explanation
Choice A:
This is the correct choice. An unstageable pressure ulcer is a wound that has full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. The blackened area in the center of the wound suggests the presence of eschar.
Choice B:
A stage 2 pressure ulcer involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This does not match the description of the wound.
Choice C:
Deep tissue injury is a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. This does not match the description of the wound.
Choice D:
A stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The skin may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. This does not match the description of the wound.
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