A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Apply ice packs to the perineal area.
Monitor for signs of postpartum seizures.
Monitor for signs of strained perineum.
Administer prescribed medications.
Correct Answer : A,C
A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Excessive uterine enlargement is a common finding in a client with a hydatidiform mole. This is due to the overgrowth of trophoblastic tissue, which forms the placenta.
Choice B rationale
Profuse, clear vaginal discharge is not typically associated with a hydatidiform mole. The most common symptom is vaginal bleeding, which can be dark brown or bright red, and sometimes is described as looking like prune juice.
Choice C rationale
An irregular fetal heart rate is not a typical finding in a client with a hydatidiform mole, as this condition often results in a nonviable pregnancy.
Choice D rationale
A rapid decline in human chorionic gonadotropin (hCG) levels is not expected in a client with a hydatidiform mole. In fact, hCG levels are usually abnormally high in these cases.
Correct Answer is A
Explanation
Choice A rationale: Uteroplacental insufficiency causes late decelerations due to reduced oxygenation, not mechanical pressure. It reflects placental dysfunction, not direct cranial compression effects.
Choice B rationale: Spontaneous rupture of membranes increases infection and labor risk but does not directly alter cerebral perfusion or trigger vagal responses linked to head compression.
Choice C rationale: Altered fetal cerebral blood flow results from cranial pressure during contractions, triggering vagal stimulation and early decelerations. This is the physiological response to head compression.
Choice D rationale: Umbilical cord compression causes variable decelerations due to transient blood flow obstruction, unrelated to cranial pressure or cerebral perfusion changes.
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