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.

Choice A rationale
Risk for injury related to seizures is an important nursing diagnosis for this client. The client is at risk of seizures due to the severe preeclampsia and the high blood pressure. Seizures can cause injury to the client and the fetus, as well as complications such as aspiration, cerebral hemorrhage, and coma. The nurse should monitor the client's neurological status, administer anticonvulsants as prescribed, and protect the client from injury during a seizure.

Choice B rationale
Impaired gas exchange related to pulmonary edema is an important nursing diagnosis for this client. The client is at risk of pulmonary edema due to the fluid overload and the high blood pressure. Pulmonary edema can impair the gas exchange and oxygen delivery to the client and the fetus, as well as cause respiratory distress, heart failure, and death. The nurse should monitor the client's respiratory status, administer oxygen as prescribed, and restrict the fluid intake.

Choice C rationale
Deficient fluid volume related to diuresis is not an important nursing diagnosis for this client. The client is not at risk of deficient fluid volume, but rather fluid overload. Diuresis is the increased production and excretion of urine, which can cause fluid loss and dehydration. The client does not have any signs of diuresis, such as increased urine output, decreased specific gravity, or weight loss.

Choice D rationale
Ineffective tissue perfusion related to placental abruption is not an important nursing diagnosis for this client. The client is not at risk of placental abruption, but rather uteroplacental insufficiency. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause bleeding, pain, and fetal distress. The client does not have any signs of placental abruption, such as vaginal bleeding, abdominal tenderness, or fetal heart rate abnormalities.

Choice A rationale
This is correct because hyperinsulinemia is the most likely cause of the respiratory distress in the newborn. Hyperinsulinemia is a condition where the newborn has high levels of insulin in the blood, due to the exposure to the mother's high blood glucose levels during pregnancy. Insulin causes the breakdown of glucose and the production of carbon dioxide, which increases the respiratory demand and leads to respiratory distress syndrome.

Choice B rationale
This is incorrect because increased deposits of fat in the chest and shoulder area are not the most likely cause of the respiratory distress in the newborn. Increased deposits of fat are a characteristic of macrosomia, which is a condition where the newborn has a birth weight of more than 4,000 g. Macrosomia can cause difficulty in delivery and increase the risk of birth injuries, but it does not directly affect the respiratory function of the newborn.

Choice C rationale
This is incorrect because brachial plexus injury is not the most likely cause of the respiratory distress in the newborn. Brachial plexus injury is a condition where the nerves that supply the arm and hand are damaged during delivery, due to excessive traction or compression. Brachial plexus injury can cause weakness, numbness, or paralysis of the affected arm, but it does not affect the respiratory function of the newborn.

Choice D rationale
This is incorrect because increased blood viscosity is not the most likely cause of the respiratory distress in the newborn. Increased blood viscosity is a condition where the blood is thicker and flows more slowly, due to the high concentration of red blood cells. Increased blood viscosity can increase the risk of thrombosis and polycythemia, but it does not directly affect the respiratory function of the newborn.