Which of the following are signs and symptoms of placenta abruption? (Select all that apply))

Choice A rationale

While taking antipsychotics is important, the nurse’s immediate priority should be to assess for harm to the patient or infant, which poses an immediate danger.

Choice B rationale

Monitoring the infant’s health is important but secondary to ensuring the patient and infant's immediate safety from potential harm due to psychosis.

Choice C rationale

Assessing thoughts of harm is crucial in postpartum psychosis as it helps in identifying immediate risks to the patient and infant, allowing for timely interventions.

Choice D rationale

Reviewing the medical record for bipolar disorder is important for treatment planning but not as immediately critical as assessing for thoughts of harm.

Choice A rationale

A boggy uterus indicates uterine atony, a leading cause of postpartum hemorrhage, as the uterus fails to contract effectively to compress blood vessels.

Choice B rationale

Moderate lochia rubra is expected postpartum vaginal bleeding, representing normal shedding of the uterine lining, not specifically indicating hemorrhage risk.

Choice C rationale

A first-degree perineal laceration is a minor tear that does not significantly increase the risk for postpartum hemorrhage as it usually involves limited bleeding.

Choice D rationale

Hypotension alone does not increase the risk for postpartum hemorrhage; however, it could be a result of ongoing hemorrhage rather than a cause.