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?
Urinary retention
Poor involution
Infection
Hemorrhage
The Correct Answer is A
Choice A rationale
Uterine atony refers to a soft and weak uterus after childbirth. It happens when your uterine muscles don’t contract enough to clamp the placental blood vessels shut after childbirth. This can lead to life-threatening blood loss after delivery. One of the causes of uterine atony is urinary retention. When the bladder is full, it can displace the uterus, preventing it from contracting properly. This can lead to uterine atony and postpartum hemorrhage. Therefore, urinary retention can cause uterine atony and lateral displacement of the fundus.
Choice B rationale
Poor involution of the uterus is a condition where the uterus does not return to its normal size after childbirth. While poor involution can lead to prolonged bleeding, it does not directly cause uterine atony. Uterine atony is specifically a lack of muscle contraction, while poor involution is a failure of the uterus to reduce in size.
Choice C rationale
While infection can lead to many complications during the postpartum period, it is not a direct cause of uterine atony. Infections can cause endometritis, which is inflammation of the uterine lining, but this does not prevent the uterus from contracting.
Choice D rationale
Hemorrhage, or heavy bleeding, is a result of uterine atony, not a cause. When the uterus does not contract properly after childbirth, it can lead to excessive bleeding, or hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Maternal bradycardia refers to a slower than normal heart rate in the mother. While it can affect the baby’s health, it doesn’t cause late decelerations on the fetal monitor.
Choice B rationale
Late decelerations are caused by uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. This is why the nurse would interpret late decelerations as indicating uteroplacental insufficiency.
Choice C rationale
Umbilical cord compression can cause variable decelerations, not late decelerations. Variable decelerations are abrupt decreases in the fetal heart rate, typically associated with contractions, and they vary in onset, depth, and duration.
Choice D rationale
Fetal head compression typically causes early decelerations, not late decelerations. Early decelerations are a mirror image of the contraction and are generally not a concern.
Correct Answer is ["90"]
Explanation
The correct answer is less than 90 beats per minute.
Step 1 is to understand the guidelines for administering digoxin to infants. According to the American Academy of Pediatrics, the nurse should withhold the dose if the infant’s apical heart rate is less than 90 beats per minute.
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