A nurse is caring for a 34-year-old female client who is 2 days postpartum in the postpartum unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Condition

Subinvolution refers to delayed uterine involution, often due to retained placental fragments or infection. The boggy uterus, excessive lochia, and passage of clots are hallmark signs. The history of postpartum hemorrhage increases risk, and fundal tenderness suggests uterine atony rather than infection or hematoma formation.

Rationale for Correct Actions

Oxytocin enhances uterine contractions to reduce bleeding and facilitate involution by increasing myometrial tone. Methylergonovine is a potent uterotonic that further supports contraction, decreasing hemorrhage risk, but must be used cautiously in hypertensive patients.

Rationale for Correct Parameters

Saturated perineal pads track blood loss severity, guiding interventions for ongoing hemorrhage. Excessive bleeding may require further medical management. Hemoglobin and hematocrit assess for anemia due to blood loss, guiding transfusion decisions if needed.

Rationale for Incorrect Conditions

Postpartum preeclampsia presents with hypertension and proteinuria, not uterine atony. Perineal hematoma manifests as localized swelling with severe perineal pain, which is absent here. Thrombophlebitis involves unilateral extremity swelling and pain, not fundal tenderness or abnormal lochia.

Rationale for Incorrect Actions

Ice packs to the perineum manage hematomas, not uterine atony. Anticoagulants are used for thromboembolic prevention, not postpartum bleeding. Quiet environment is relevant for preeclampsia, not uterine subinvolution.

Rationale for Incorrect Parameters

Seizures are relevant to preeclampsia, not uterine subinvolution. Calf circumference is monitored for thrombophlebitis, which is absent here. Rectal pain is not an expected indicator of uterine involution status.

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Correct Answer is C

Explanation

Choice A rationale

Oral contraceptives primarily work by inhibiting ovulation through hormonal regulation. They do not inherently increase the risk of pelvic inflammatory disease (PID). In some cases, they may even offer a protective effect against PID by thickening cervical mucus, which can act as a barrier to ascending infections.

Choice B rationale

Frequent alcohol use can impair the immune system, potentially making an individual more susceptible to infections. However, it is not a direct cause of PID. PID is primarily caused by ascending infections, often sexually transmitted infections, rather than the direct effects of alcohol consumption.

Choice C rationale

Chlamydia trachomatis is a common sexually transmitted bacterium and a major cause of pelvic inflammatory disease. Untreated chlamydia infections can ascend from the cervix and uterus to the fallopian tubes and ovaries, leading to inflammation, scarring, and potentially long-term complications such as infertility and ectopic pregnancy.

Choice D rationale

Recurrent cystitis, an infection of the bladder, primarily affects the lower urinary tract. While urinary tract infections are common in women, they do not typically ascend to the reproductive organs and cause pelvic inflammatory disease. PID involves infection of the upper genital tract, including the uterus, fallopian tubes, and ovaries.

A. Monitor deep tendon reflexes hourly. B. Notify the physician if urinary output is less than 30 ml per hour. C. Keep calcium gluconate on hand in case of a magnesium sulfate overdose. D. Monitor maternal vital signs every 6 hours. E. Monitor intake and output hourly. F. Monitor renal function and cardiac function closely.

Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A rationale

Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.

Choice B rationale

A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.

Choice C rationale

Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.

Choice E rationale

Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.

Choice F rationale

Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.

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Naxlex Comprehensive Predictor Exams

A nurse in a woman's health clinic is obtaining a health history from a client.Which of the following findings should the nurse identify as increasing the client's risk for developing pelvic inflammatory disease (PID)?

Correct Answer is C

Explanation

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.Select all nursing interventions that apply in the care for the client.

Correct Answer is ["A","B","C","E","F"]

Explanation

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