35-year-old postpartum client.

Select the condition, risk factors and assessment findings that the client may be experiencing.

Answer and Explanation

The Correct Answer is []

Condition: Postpartum Hemorrhage (PPH)

Postpartum hemorrhage is defined as blood loss ≥ 500 mL after vaginal delivery or ≥ 1000 mL after cesarean delivery. In this case, the client has heavy bleeding, large clots, and lightheadedness, which are key indicators of excessive postpartum blood loss.

Risk Factors

1. Fetal Macrosomia: The baby weighs 9 lbs 4 oz (4196 grams), which is considered macrosomia (birth weight > 4000 g). Large fetal size increases the risk of uterine overdistension, which can impair uterine contractions and lead to uterine atony, the most common cause of postpartum hemorrhage.

2. Uterine Atony: The nurse initially noted a boggy uterus that required massage to become firm. Uterine atony occurs when the uterus fails to contract effectively after delivery, leading to excessive bleeding. This is the leading cause of PPH.

3. Prolonged Labor: A prolonged labor can cause uterine fatigue, reducing the uterus's ability to contract properly after delivery, thereby increasing the risk of uterine atony and PPH.

Assessment Findings

1. Heavy vaginal bleeding: The client has heavy bleeding with three quarter-sized clots, which is abnormal postpartum and indicates excessive blood loss.

2. Blood pressure: The client’s BP is 150/86 mmHg, which may indicate compensatory vasoconstriction due to ongoing blood loss. If hemorrhage continues, hypotension may develop.

3. Urine output: The client did not feel the urge to void, and catheterization drained 450 mL of urine. A full bladder can prevent proper uterine contraction, worsening uterine atony and bleeding.

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Correct Answer is B

Explanation

A. Observe an area of redness on the breast of a client who is 1 day postpartum.
Assessment is outside the scope of practice for an AP. The nurse must assess the redness, as it could indicate mastitis or engorgement requiring further evaluation.

B. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
Assisting with hygiene and comfort measures, such as a sitz bath, is within the AP’s scope of practice. The nurse should ensure that the client understands proper perineal care and has no contraindications.

C. Monitor vital signs during admission of a client who has gestational hypertension.
Clients with gestational hypertension require close monitoring, and initial admission assessments, including vital signs, must be performed by the nurse to identify signs of preeclampsia or worsening hypertension.

D. Change the initial perineal pad of a client who just transferred from labor and delivery.
The first perineal pad change is an assessment opportunity for the nurse, allowing them to evaluate bleeding amount, presence of clots, and signs of postpartum hemorrhage. The nurse should perform the initial assessment and pad change before delegating routine hygiene tasks to the AP.

A. Retained placental fragments B. Uterine atony C. Puerperal infection D. Thrombophlebitis

Correct Answer is B

Explanation

A. Retained placental fragments
This is incorrect because retained placental fragments are more commonly associated with prolonged third-stage labor or incomplete placental expulsion, rather than fetal macrosomia.

B. Uterine atony
This is correct because a large baby (macrosomia) causes overdistension of the uterus, increasing the risk of uterine atony (failure of the uterus to contract effectively). This can lead to postpartum hemorrhage.

C. Puerperal infection
This is incorrect because puerperal infection is usually related to prolonged rupture of membranes, poor hygiene, or invasive procedures, rather than fetal size alone.

D. Thrombophlebitis
While pregnancy increases the risk of clot formation, the most immediate concern for this client is uterine atony and postpartum hemorrhage.

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35-year-old postpartum client. Select the condition, risk factors and assessment findings that the client may be experiencing.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is B

Explanation

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

Correct Answer is B

Explanation

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35-year-old postpartum client.

Select the condition, risk factors and assessment findings that the client may be experiencing.