A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit.
The nurse knows that assessment for which complication is the highest priority for this client?

Disseminated intravascular coagulation (DIC).

Postpartum psychosis.

Hard, painful uterine afterpains.

Placenta accreta.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Disseminated intravascular coagulation (DIC) is a serious complication that can occur after severe postpartum hemorrhage. It involves an abnormal activation of the clotting cascade, leading to the formation of small blood clots in the vessels and can result in organ damage.

Choice B rationale

Postpartum psychosis is a rare psychiatric emergency that typically presents with delirium and mood disturbances, and it is not directly related to postpartum hemorrhage.

Choice C rationale

While hard, painful uterine afterpains can occur after childbirth, they are not the highest priority for assessment in a client who experienced a severe postpartum hemorrhage.

Choice D rationale

Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. However, it is typically identified during pregnancy or at the time of delivery, not after a postpartum hemorrhage.

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Correct Answer is B

Explanation

Choice A rationale

Preparing a vacuum is not the first action to take when the fetal head retracts against the perineum during the second stage of labor.

Choice B rationale

Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.

Choice C rationale

Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.

Choice D rationale

Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.

A. Praise the client for her actions and offer to discuss ways to decrease consumption even more. B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit. C. Notify child protective services of the client’s illicit drug use and probable child endangerment. D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Correct Answer is A

Explanation

The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.

Here’s why the other options are incorrect:

B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.

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A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for which complication is the highest priority for this client?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse anticipate performing to assist the healthcare provider?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

Correct Answer is A

Explanation

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A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit.
The nurse knows that assessment for which complication is the highest priority for this client?