A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?
Encourage the client to nurse more frequently so her milk will come in
Report the client's temperature elevation
Ask the client to empty her bladder
Increase IV fluids
The Correct Answer is C
ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.
Choice A is not correct because the client's milk will come in regardless of nursing frequency.
Choice B is not correct because the client's temperature is within normal limits.
Choice D is not correct because there is no indication of an increase in IV fluids.
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Correct Answer is D
Explanation
Precipitous birth
This is because precipitous birth, which is defined as a labor that lasts less than three hours from the onset of contractions to delivery, is a risk factor for postpartum hemorrhage. This is because the uterus may not contract well after a rapid delivery, leading to uterine atony and bleeding. Other risk factors for postpartum hemorrhage include uterine overdistension, oxytocin use, placental abruption, placenta previa, infection, coagulation disorders, and previous history of postpartum hemorrhage.
Choice A is not correct because gestational hypertension is not a risk factor for postpartum hemorrhage. It is a condition that causes high blood pressure during pregnancy and can lead to complications such as preeclampsia, eclampsia, and placental abruption³.
Choice B is not correct because small for gestational age newborn is not a risk factor for postpartum hemorrhage. It is a condition that indicates that the baby's growth was restricted in the womb and weighs less than 90% of other babies of the same gestational age. It can be caused by maternal factors, placental factors, or fetal factors⁴.
Choice C is not correct because a two-vessel umbilical cord is not a risk factor for postpartum hemorrhage. It is a condition that occurs when the umbilical cord has only one artery and one vein instead of the normal two arteries and one vein. It can be associated with congenital anomalies, intrauterine growth restriction, and stillbirth.
Correct Answer is B
Explanation
Fundus firm, at the level of the umbilicus. This is because the normal postpartum uterine fundus location should be around the belly button (umbilicus) one hour after delivery and then decrease by 1 cm per 24 hours. A firm fundus indicates that the uterus is contracting well and preventing bleeding.
Choice A is wrong because a soft fundus indicates uterine atony, which is a risk factor for hemorrhage.
Choice C is wrong because the fundus should not be above the umbilicus 12 hours after delivery.
Choice D is wrong because a fundus to the right of the umbilicus indicates a full bladder, which can displace the uterus and cause bleeding.
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