A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Gestational hypertension

Small for gestational age newborn

Two-vessel umbilical cord

Precipitous birth

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.

Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.

Mucus drainage does not interfere with breathing unless it is excessive or thick.

Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.

Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.

A. Document expected postpartum mucous membrane congestion B. Notify the charge nurse of a possible upper respiratory infection C. Notify the physician of a possible pulmonary embolism D. Medicate with antipyretic remedy for elevated temperature

Correct Answer is C

Explanation

Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threateningcondition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.

Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.

Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.

Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.

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A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:

Correct Answer is D

Explanation

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

Correct Answer is C

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

To protect newborns from infection while in the nursery, the nurse plans to:

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?