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A nurse is caring for a patient who is 36 hours postpartum.

Exhibits

After reviewing the information in the patient’s medical record, which of the following complications pose a greater
risk for the patient?

A.

Perineal pad clots

B.

Pelvic pain

C.

Boggy uterus

D.

Breast Engorgement

Answer and Explanation

The Correct Answer is C

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.


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Related Questions

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Cerebral manifestations such as a mild headache can be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. This should be reported to the provider.

Choice B rationale

Gastrointestinal assessment findings such as heartburn can be common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach. However, severe or persistent heartburn may indicate a more serious condition like gastroesophageal reflux disease (GERD) or preeclampsia. This should be reported to the provider.

Choice C rationale

Respiratory rate alone, without knowing whether it’s increased, decreased, or normal, is not enough information to determine if it should be reported to the provider.

Choice D rationale

Deep tendon reflexes can be hyperactive in clients with preeclampsia. An increase in deep tendon reflexes can be a sign of worsening preeclampsia and should be reported to the provider.

Correct Answer is B

Explanation

Choice A rationale

Intermittent abdominal pain following the passage of bloody mucus can be a sign of labor or other complications, but it is not a typical finding that supports the diagnosis of placenta previa.

Choice B rationale

Painless red vaginal bleeding is a classic symptom of placenta previa. This occurs because the placenta is covering part or all of the cervix, leading to bleeding as the cervix begins to thin and open in preparation for labor.

Choice C rationale

Abdominal pain with scant red vaginal bleeding could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.

Choice D rationale

Increasing abdominal pain with a non-relaxed uterus could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.

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