Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.

Choice A rationale

The largest fetal diameter passing through the pelvic outlet is not what is indicated by the presenting part being at 0 station. This would be more indicative of a positive station, such as

+31.

Choice B rationale

The position of the fetal head, such as left occiput posterior, is not determined by the station of the presenting part. The station refers to the level of the presenting part in relation to the mother’s ischial spines.

Choice C rationale

The palpability of the posterior fontanel is not related to the station of the presenting part. The fontanels are soft spots on the baby’s head which allow for compression during birth and brain growth after birth.

Choice D rationale

This is the correct interpretation of the clinical finding. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines.