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 C

Explanation

Choice A rationale
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. While it can have serious implications for the mother and baby, it is not directly linked to the development of spina bifida occulta in the newborn.
Choice B rationale
Tobacco use during pregnancy can lead to several complications, including low birth weight, preterm birth, and certain birth defects. However, it is not identified as a significant risk factor for spina bifida occulta.
Choice C rationale
Folic acid deficiency during pregnancy is a well-known risk factor for neural tube defects, including spina bifida. Spina bifida occulta is a mild form of spina bifida caused by a gap forming between the vertebrae in the spinal cord during fetal development. Adequate intake of folic acid, especially during the early stages of pregnancy, can help prevent such defects.
Choice D rationale
Short interval pregnancy refers to pregnancies that are closely spaced. While they can lead to complications such as preterm birth and low birth weight, they are not directly associated with an increased risk of spina bifida occulta.

A. To prevent herpes infection B. To prevent eye infections C. To clear the infant’s vision D. To dilate the pupil so the red reflex can be visualized E. To dilate the pupil so the red reflex can be viWhat would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

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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

A newborn’s assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

Correct Answer is C

Explanation

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

After a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse is preparing the family for discharge. Monitor the infant for response to auditory stimuli.

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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?

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The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia. What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?

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?

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?