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.
Placenta accreta.
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
While it’s important to evaluate the parent’s ability to care for the child, this does not directly address the parent’s fear of needles. The parent’s fear of needles is a specific issue that needs to be addressed in order to ensure the child receives the necessary insulin injections.
Choice B rationale
Determining if the child can administer the insulin is a potential solution to the parent’s fear of needles. Some children as young as 10 years old may be able to administer their own insulin injections with proper training and supervision. This would allow the child to manage their diabetes independently and alleviate the parent’s fear of needles.
Choice C rationale
Encouraging the parent to handle the needles may not be effective if the parent has a significant fear of needles. It’s important to respect the parent’s fear and find alternative solutions, such as having the child administer the insulin or finding another person who can assist with the injections.
Choice D rationale
Inquiring if there is another person who can assist with the injections is a potential solution to the parent’s fear of needles. If there is another person available who is comfortable administering the insulin injections, this could alleviate the parent’s fear and ensure the child receives the necessary care.
Correct Answer is B
Explanation
Choice A rationale
Low risk: Routine monitoring. This choice is not the most appropriate. While routine monitoring is important for all patients, those receiving the MMR vaccine are not at an increased risk for Venous Thromboembolism (VTE) or Postpartum Hemorrhage (PPH) based solely on the administration of this vaccine.
Choice B rationale
Moderate to high risk: Initiate VTE prophylaxis per policy. This choice is the most appropriate. The risk of VTE and PPH should be evaluated based on the patient’s overall health status, pregnancy history, and current condition. If the patient is determined to be at moderate to high risk, VTE prophylaxis should be initiated per policy.
Choice C rationale
Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
Choice D rationale
High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
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