When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?
Thromboembolism
Cervical laceration
Hemorrhoids
Hemorrhage
The Correct Answer is D
Hemorrhage. This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.
Choice A is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.
Choice B is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.
Choice C is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.
Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.
Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.
Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.
Correct Answer is D
Explanation
Wash hands before touching each baby. This is because hand hygiene is the most effective way to prevent infection transmission in the nursery. Hand hygiene should be performed before and after every patient contact, as well as before and after wearing gloves or handling equipment. Hand hygiene can be done by washing hands with soap and water or using alcohol-based hand rubs.
Choice A is not correct because adjusting room temperature between 75°F and 80°F is not a measure to protect newborns from infection. The room temperature should be maintained within a comfortable range for newborns, but it does not affect infection risk.
Choice B is not correct because wearing a disposable gown when giving infant care is not a measure to protect newborns from infection. Disposable gowns are part of contact precautions, which are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. They are not necessary for routine infant care.
Choice C is not correct because keeping the newborn dressed warmly is not a measure to protect newborns from infection. Keeping the newborn dressed warmly can help prevent heat loss and hypothermia, but it does not affect infection risk.
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