A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.
Exhibits
The nurse is assessing the client 1 hour later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.

Fundus 2 cm above umbilicus

Blood pressure 90/60 mm Hg

Heart rate 110/min

Continued heavy vaginal bleeding

Client reports feeling dizzy

Cloudy urine

Answer and Explanation

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

•   Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
•   Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
•   Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
•   Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
•   Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
•   Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.

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Correct Answer is D

Explanation

Choice A rationale
Administering a 500 mL lactated Ringer’s IV bolus is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice B rationale
Documenting urinary output is important, but it is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice C rationale

Replacing the surgical dressing is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice D rationale
Notifying the healthcare provider is the correct action. Persistent vaginal bleeding after a cesarean birth could indicate a postpartum hemorrhage, which is a medical emergency

A. Patient who has a urinary output of 300 ml in 8 hours B. Patient who reports lochia rubra requiring changing perineal pads every 3 hours C. Patient who is receiving magnesium sulfate and has absent deep tendon reflexes D. Patient who reports abdominal cramping during breastfeeding

Correct Answer is C

Explanation

Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale

A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on the postpartum unit is caring for four patients. For which of the following patients should the nurse notify the provider?

Correct Answer is C

Explanation

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