A nurse is caring for a 30-year-old female client who is 36 hours postpartum in the postpartum unit.
After reviewing the information in the client’s medical record, which of the following complications poses a greater risk for the client? Complete the following sentence by using the list of options:
The complication that poses the greatest risk for the client is
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The complication that poses the greatest risk for the client is hemorrhage as evidenced by their amount of lochia.
Rationale for correct answers
Postpartum hemorrhage (PPH) is a major concern when excessive lochia and a boggy uterus are present. The nurse’s assessment reveals a boggy fundus, which firmed with massage but then softened again, indicating uterine atony, a leading cause of PPH. Additionally, the saturation of the perineal pad with lochia rubra and small clots suggests ongoing bleeding that requires close monitoring.
Rationale for incorrect Response 1 options
- Infection: No fever (≥38°C or 100.4°F) or foul-smelling lochia, which would indicate postpartum endometritis.
- Thrombophlebitis: No calf pain, swelling, or localized tenderness suggesting deep vein thrombosis.
- Mastitis: Breasts are soft, warm, and tender but without redness or localized pain, making mastitis unlikely.
Rationale for incorrect Response 2 options
- Breast tenderness: Expected due to milk production, not indicative of infection or complications.
- Calf pain: No evidence of thrombophlebitis or deep vein thrombosis.
- Fever: Temperature is normal at 37.2°C, ruling out systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Immediately postpartum, the fundus is typically palpable. It gradually descends into the pelvic cavity over the following days.
Choice B rationale
By 6 to 12 hours postpartum, the fundus is usually located at the level of the umbilicus or slightly below it. It descends approximately one fingerbreadth (1 cm) per day.
Choice C rationale
In the immediate postpartum period, within the first few hours after delivery, the nurse should expect to find the fundus at the level of the umbilicus. This indicates that the uterus is contracting to control bleeding at the placental site.
Choice D rationale
Immediately after delivery, the fundus is typically higher than the symphysis pubis. It descends into the abdomen as the uterus contracts and the placental site begins to heal. .
Correct Answer is D
Explanation
Choice A rationale
Puerperal infection, an infection of the reproductive tract after childbirth, is a risk factor for all postpartum women. However, a large newborn size (macrosomia) increases the risk of prolonged labor, increased instrumentation during delivery, and postpartum hemorrhage, which indirectly increases the risk of infection but is not the most direct immediate risk related to the newborn's weight.
Choice B rationale
Retained placental fragments are a risk factor when the placenta does not deliver intact. While a large newborn can sometimes be associated with difficulties during placental delivery, it is not the primary direct risk factor immediately following birth. Uterine atony is a more immediate and direct risk related to uterine overdistension.
Choice C rationale
Thrombophlebitis, the formation of blood clots in the veins, is a postpartum risk factor related to hormonal changes, immobility, and hypercoagulability. While factors like prolonged labor (more common with large babies) can contribute, it is not the most immediate and direct risk in the first few hours postpartum for a woman who delivered a large newborn.
Choice D rationale
A newborn weighing 9 lb 6 oz (4252 g) is considered macrosomic. This large size can lead to overdistension of the uterus during pregnancy and labor. Uterine overdistension impairs the ability of the uterine muscles to contract effectively after delivery, a condition known as uterine atony. Uterine atony is the primary and most immediate risk for postpartum hemorrhage in women who have delivered large newborns. .
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