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

Resting in a recliner until the incision is healed is not recommended following a cesarean birth. It’s important for the client to gradually increase their activities and mobility to promote healing and prevent complications such as blood clots.

Choice B rationale

It’s crucial for the client to monitor their incision for signs of infection, such as increased redness, swelling, pain, or discharge. Therefore, calling the provider if there is discharge from the incision indicates understanding of the discharge instructions.

Choice C rationale

Resuming prenatal vitamins is often recommended after a cesarean birth to aid in recovery and support breastfeeding if the client chooses to breastfeed. Prenatal vitamins contain essential nutrients that can help the client heal and recover after surgery.

Choice D rationale

Unrelieved abdominal pain is not a normal part of recovery and could indicate a complication such as an infection or a problem with the incision. Therefore, the client should understand that they should not have unrelieved pain in their abdomen and should contact their provider if they do.