When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?
She is a gravida 6, para 5.
She received butorphanol 2 mg IV during labor.
She is over 35 years of age.
The second stage of labor lasted 10 minutes.
The Correct Answer is A
Rationale:
A. She is a gravida 6, para 5: A high parity (multiple previous births) stretches the uterus significantly over time, increasing the risk of uterine atony—a leading cause of postpartum hemorrhage due to the uterus failing to contract effectively.
B. She received butorphanol 2 mg IV during labor: Butorphanol is a narcotic analgesic and does not directly contribute to excessive postpartum bleeding or uterine atony in typical doses.
C. She is over 35 years of age: Advanced maternal age can increase some obstetric risks, but it is not as directly associated with postpartum hemorrhage as high parity.
D. The second stage of labor lasted 10 minutes: A short second stage may lead to perineal trauma, but it is less likely to cause excessive vaginal bleeding compared to uterine atony from high parity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Place a foam surface on top of the mattress: A foam surface may help reduce pressure, but for a stage IV pressure injury with eschar, this alone is insufficient. More advanced pressure redistribution systems are needed for adequate management of severe wounds.
B. Raise the head of the bed only to 30 degrees: Limiting the head-of-bed elevation helps reduce shear forces, which worsen pressure injuries, especially over the sacrum. This intervention is critical for preventing further tissue damage and promoting healing of deep wounds with eschar.
C. Perform passive range of motion exercises: While passive ROM supports circulation and prevents contractures, it does not directly address pressure relief or eschar management. It's beneficial, but not the top priority for treating a stage IV ulcer.
D. Increase the daily intake of vitamin C: Vitamin C supports collagen synthesis and immune function, aiding wound healing. However, nutrition alone cannot address mechanical factors like pressure and shear, which are primary contributors to pressure injury progression.
Correct Answer is D
Explanation
Rationale:
A. Decreased urinary output: While decreased output may signal fluid imbalance or poor perfusion, it is not as immediately life-threatening as a cardiac arrhythmia. It should be monitored, but other findings take precedence in an acute setting.
B. Profound weight gain: Rapid weight gain suggests fluid retention, possibly from corticosteroid imbalance, but it does not pose an immediate danger compared to cardiac instability. It requires intervention but is not emergent.
C. Low blood glucose levels: Hypoglycemia is common after adrenalectomy due to cortisol deficiency and must be treated, but symptoms often develop gradually and are managed with glucose replacement. It is serious but not as acutely life-threatening as arrhythmias.
D. Ventricular arrhythmias: This finding indicates severe electrolyte disturbances—especially hyperkalemia, which can occur after adrenalectomy due to aldosterone deficiency. It poses an immediate threat to cardiac function and requires urgent intervention.
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