The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention?
Respiratory rate of 16 breaths/min
Pulse of 120 beats per minute
Temperature of 98.8 F (37.7 C)
Blood pressure of 120/88 mmHg
The Correct Answer is B
A. Respiratory rate of 16 breaths/min: Normal range, no intervention needed.
B. Pulse of 120 beats per minute: Correct. Tachycardia in the postpartum period can indicate hemorrhage or hypovolemia, requiring immediate assessment and intervention.
C. Temperature of 98.8°F (37.7°C): Normal postpartum temperature.
D. Blood pressure of 120/88 mmHg: Normal postpartum blood pressure.
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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
The nurse should recognize that the client is at risk of postpartum hemorrhage due to polyhydramnios.
Risk:
Postpartum Hemorrhage (PPH): The client has polyhydramnios and multiple gestation, which cause uterine overdistension. Overdistension increases the risk of uterine atony postpartum, a leading cause of PPH. Other contributing factors are the large uterine fibroids and a history of preterm labor.
Probable Cause:
Polyhydramnios: AFI of 30 cm indicates polyhydramnios, which is excess amniotic fluid.
Multiple gestation (twins) is a common cause of polyhydramnios. Polyhydramnios increases the risk of preterm labor, cord prolapse, and PPH.
Correct Answer is B
Explanation
A. G2P1 (second pregnancy, one prior birth) may experience some afterbirth pains, but G3P2 is at higher risk.
B. Multiparous clients (those who have had multiple pregnancies) are more likely to experience stronger afterbirth pains due to repeated uterine stretching and contractions. Additionally, delivering a large baby (macrosomia) increases uterine involution and associated pain.
C. First-time mothers (G1P1) typically experience milder afterbirth pains due to a less stretched uterus.
D. G3P0 (three pregnancies, no births) suggests preterm labor without full-term delivery, making afterbirth pains unlikely.
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