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 D
Explanation
Choice A rationale
Placing a pulse oximeter on the heel of a newborn can help monitor oxygen saturation levels. However, the symptoms described, such as jitteriness, hypotonicity, and a weak cry, are more indicative of hypoglycemia, a condition that would not be detected by a pulse oximeter.
Choice B rationale
Swaddling the infant in a warm blanket can help maintain body temperature, but it does not address the underlying cause of the symptoms, which are suggestive of hypoglycemia.
Choice C rationale
Documenting the findings in the record is an important part of nursing care, but it does not provide immediate intervention for the symptoms observed.
Choice D rationale
Obtaining a heel stick blood glucose level is the appropriate action given the symptoms described. Jitteriness, hypotonicity, and a weak cry can be signs of neonatal hypoglycemia. Prompt diagnosis and treatment are essential to prevent potential complications.
Correct Answer is D
Explanation
Choice A rationale
Obtaining blood cultures is not the first action to take in this situation. Blood cultures would be used to identify a bloodstream infection, which is not indicated by the client’s current symptoms.
Choice B rationale
Covering the lesion with a dressing is not the appropriate action. Herpes lesions are highly contagious, and covering them does not eliminate the risk of transmission during vaginal delivery.
Choice C rationale
Administering penicillin is not the appropriate action. Penicillin is an antibiotic used to treat bacterial infections, not viral infections like herpes.
Choice D rationale
Preparing for a cesarean section is the correct action. A cesarean section is recommended for women with active genital herpes lesions or prodromal symptoms at the time of labor to prevent transmission of the virus to the newborn during delivery.
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