A nurse is caring for a 30-year-old female client who is 36 hours postpartum in the postpartum unit.

Exhibits

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
dropdown
as evidenced by their
dropdown
.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
Uterine findings: Expected—firm and midline uterus indicating effective involution.
Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
Blood pressure: Expected—within normal postpartum range.

A. The fetus may be in a breech presentation. B. The fetus is likely in the left occiput anterior position. C. The fetus may have polyhydramnios. D. The fetus is likely in the right occiput posterior position.

Correct Answer is A

Explanation

Choice A rationale

When the fetal heart tones are heard loudest in the upper right abdominal quadrant above the umbilicus, it suggests that the fetal back, which transmits sound most clearly, is located in that area. In a breech presentation, the fetal buttocks or feet are in the lower uterine segment, and the head is in the upper portion of the uterus. Therefore, the fetal heart sounds would be best auscultated in the upper abdomen.

Choice B rationale

In the left occiput anterior (LOA) position, the fetal occiput is in the left anterior quadrant of the maternal pelvis. The fetal heart tones are typically heard loudest in the lower left quadrant of the maternal abdomen because the fetal back is usually anterior and slightly to the left.

Choice C rationale

Polyhydramnios is an excessive amount of amniotic fluid. While it can sometimes make it more difficult to auscultate fetal heart tones clearly due to increased fluid volume, it does not directly correlate with the location where the heart tones are heard loudest. The position of the fetus is the primary determinant of the auscultation location.

Choice D rationale

In the right occiput posterior (ROP) position, the fetal occiput is in the right posterior quadrant of the maternal pelvis. The fetal heart tones would typically be heard loudest in the lower right quadrant of the maternal abdomen, as the fetal back would be positioned posteriorly and to the right.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

The labor and delivery nurse caring for a client at 39 weeks gestation notes that the fetal heart tone is heard most loudly and clearly when auscultated in the upper right abdominal quadrant above the umbilicus.What is the nurse's best interpretation of this finding?

Correct Answer is A

Explanation

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A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period.When the nurse locates the fundus, she notes that the uterus feels soft and boggy at midline.Which of the following nursing interventions would be most appropriate initially?