The nurse is caring for a postpartum client with suspected uterine atony.
Which interventions would the nurse initiate to improve the patient's status? Select all that apply.
Increase intravenous fluid replacement.
Insert an indwelling urinary catheter.
Monitor deep tendon reflexes.
Initiate a peri-pad count.
Perform a fundal massage.
Administer tocolytic therapy.
Correct Answer : A,B,D,E
Choice A rationale
Uterine atony is the leading cause of postpartum hemorrhage, resulting in significant blood loss and hypovolemia. Increasing intravenous fluid replacement with crystalloid solutions (e.g., normal saline or lactated Ringer's) is critical to restoring circulating blood volume, maintaining hemodynamic stability, and preventing hypovolemic shock.
Choice B rationale
A full bladder can displace the uterus and impede its ability to contract effectively, contributing to or worsening uterine atony. Inserting an indwelling urinary catheter (Foley catheter) ensures continuous bladder drainage and decompression, allowing the uterus to move into its proper place and contract more effectively.
Choice C rationale
Monitoring deep tendon reflexes (DTRs) is primarily an assessment for magnesium sulfate toxicity in clients being treated for preeclampsia or eclampsia. While relevant in those specific conditions, it is not a direct intervention for managing the immediate effects or cause of postpartum hemorrhage due to uterine atony. Normal DTR response is 2+.
Choice D rationale
Quantifying blood loss is essential for determining the severity of the hemorrhage and the efficacy of interventions. Initiating a peri-pad count and accurately weighing the pads provides a reliable, though often underestimated, measure of blood loss, guiding the need for additional fluids, blood products, or uterotonic medications.
Choice E rationale
Uterine atony is a failure of the uterine muscle to contract and compress the blood vessels at the placental site. Performing a fundal massage stimulates the myometrium to contract, thereby physically compressing the vessels and activating the natural physiological mechanisms to stop the bleeding; this is a primary, initial intervention.
Choice F rationale
Tocolytic therapy, such as terbutaline or nifedipine, works by relaxing the uterine muscle, which is used to stop preterm labor. In the context of uterine atony, the goal is to contract the uterus, so administering tocolytic therapy would be contraindicated as it would worsen the atony and accelerate blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12"]
Explanation
Step 1 is to convert the oxytocin concentration from units to milliunits (mU):. 20 units× 1000 mU/unit = 20000 mU.
Step 2 is to determine the concentration in mU/mL:. 20000 mU÷ 1000 mL = 20 mU/mL.
Step 3 is to calculate the infusion rate in mL/min:. 4 mU/min÷ (20 mU/mL) = 0.2 mL/min.
Step 4 is to convert the infusion rate from mL/min to mL/hr:. 0.2 mL/min× 60 min/hr = 12 mL/hr. The final calculated answer is 12 mL/hr.
Correct Answer is C
Explanation
Choice A rationale
Peritonitis is a severe inflammation of the peritoneum, the membrane lining the abdominal cavity, usually due to bacterial contamination from a perforated viscus or the uterus. While a serious complication of advanced puerperal infection, peritonitis presents with generalized severe abdominal rigidity, rebound tenderness, and high fever, not just an increase in localized perineal pain, which is the key symptom described.
Choice B rationale
Thrombophlebitis (or superficial vein thrombosis) involves inflammation and clotting in a vein, most commonly in the legs post-delivery. It presents with localized warmth, redness, swelling, and pain along the course of the affected vein in the calf or thigh, not primarily with increased localized pain in the perineal region, which is the anatomical area described in the report.
Choice C rationale
Infection of the perineum (often related to an episiotomy, laceration repair, or hematoma) is highly likely given the combination of a prolonged rupture of membranes (a risk factor) and the specific complaint of increasing perineal pain two days postpartum. Infection leads to localized inflammation, edema, purulent drainage, and increased pain at the perineal wound site, matching the client's symptoms and risk profile.
Choice D rationale
Endometritis is an infection of the uterine lining (endometrium), a common postpartum complication, especially after prolonged rupture of membranes. Classic signs include fever, uterine subinvolution, and foul-smelling lochia, often accompanied by lower abdominal or uterine tenderness, but increasing perineal pain points more specifically to a localized wound infection or abscess in that area.
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