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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 C

Explanation

The correct answer is Choice C. . . However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice B rationale

Applying a fetal scalp electrode is a procedure used for continuous fetal heart monitoring during labor. It provides a more accurate and consistent transmission of the fetal heart rate than external methods. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice C rationale

Changing the client’s position can help improve uteroplacental blood flow and fetal oxygenation. It is often the first action taken when late decelerations are noted in the FHR.

Choice D rationale

Increasing the rate of the IV infusion can help increase maternal blood volume and improve uteroplacental blood flow. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Correct Answer is A

Explanation

The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30

minutes old.

Choice B rationale

Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice C rationale

Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice D rationale

Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.

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