The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.
Her uterus is firm, and she has a moderate flow of lochia.
Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Heart rate and blood pressure.

Urinary output and IV fluid intake.

Hemoglobin and hematocrit levels.

Abdominal contour and bowel sounds.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client’s heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.

Choice B rationale

While monitoring urinary output and IV fluid intake can be important in the overall assessment of a postpartum client, these are not the most immediate concerns when a perineal hematoma is forming.

Choice C rationale

Checking hemoglobin and hematocrit levels can provide information about the client’s blood volume and potential blood loss. However, this would likely be done after initial vital signs are assessed and stabilized.

Choice D rationale

Assessing abdominal contour and bowel sounds would not be the most immediate concern in this situation. These assessments would be more relevant if there were concerns about postpartum complications related to the client’s gastrointestinal system.

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Correct Answer is D

Explanation

Choice A rationale

While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice B rationale

Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.

Choice C rationale

Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice D rationale

Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.

A. Abruptio placenta. B. Chorioamnionitis. C. Round ligament strain. D. Viral infection.

Correct Answer is B

Explanation

Choice A rationale

Abruptio placenta is a condition where the placenta prematurely separates from the uterus. It typically presents with symptoms such as vaginal bleeding, back pain, and frequent contractions. However, the symptoms described by the client do not align with this condition.

Choice B rationale

Chorioamnionitis is an infection of the membranes surrounding the fetus and is associated with prolonged labor. Symptoms include fever, abdominal pain, and fetal tachycardia. The client’s symptoms of pain when the baby moves, a high temperature, and severe abdominal or uterine tenderness on palpation align with this condition.

Choice C rationale

Round ligament strain is a common cause of pain during pregnancy, particularly in the second trimester. It is caused by the stretching of the round ligaments that support the uterus.

However, it does not cause fever or severe abdominal tenderness.

Choice D rationale

While a viral infection could potentially cause a fever, it would not typically cause severe abdominal or uterine tenderness specifically when the baby moves.

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The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Correct Answer is D

Explanation

A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

Correct Answer is B

Explanation

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The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.
Her uterus is firm, and she has a moderate flow of lochia.
Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?