A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is found to be displaced laterally to the right, and there is uterine atony. Which of the following is the cause of the uterine atony?

Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.

Choice A rationale
A client who has a cesarean incision that is well-approximated with no drainage is not at the greatest risk for developing a puerperal infection. While any surgical incision can potentially become infected, if the incision is healing well with no signs of infection, the risk is relatively low.
Choice B rationale
A client who does not wash her hands between perineal care and breastfeeding is increasing her risk of infection, but this is not the greatest risk factor for developing a puerperal infection. Good hand hygiene is important to prevent the spread of germs, but other factors pose a greater risk for puerperal infection.
Choice C rationale
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration is at the greatest risk for developing a puerperal infection. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. If the episiotomy extends and becomes a third-degree laceration, it involves the vaginal tissue, perineal skin, and the muscle of the perineum, and can extend into the anal sphincter, the muscle that surrounds the anus. This type of wound provides a medium for bacterial growth, increasing the risk of infection.
Choice D rationale
A client who is not breastfeeding and is using measures to suppress lactation is not at the greatest risk for developing a puerperal infection. While breastfeeding can help reduce the risk of certain types of infections, not breastfeeding does not significantly increase the risk of puerperal infection.