A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)

Newborn weight 2.948 kg (6 lb 8 oz).

History of uterine atony.

Labor induction with oxytocin.

History of human papillomavirus.

Answer and Explanation

Correct Answer : B,C

Choice A rationale:

Newborn weight of 2.948 kg (6 lb 8 oz) does not place the client at risk for postpartum hemorrhage. Newborn weight is not directly related to the risk of postpartum hemorrhage in the mother.

Choice B rationale:

History of uterine atony places the client at risk for postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage and refers to the inability of the uterus to contract effectively after childbirth, leading to excessive bleeding.

Choice C rationale:

Labor induction with oxytocin places the client at risk for postpartum hemorrhage. Oxytocin is commonly used to induce labor or augment contractions, but it can cause uterine hyperstimulation, leading to increased risk of postpartum hemorrhage.

Choice D rationale:

History of human papillomavirus (HPV) does not place the client at risk for postpartum hemorrhage. HPV is a sexually transmitted infection and does not have a direct connection to the risk of postpartum hemorrhage.

Choice E rationale:

Vacuum-assisted delivery places the client at risk for postpartum hemorrhage. Vacuum assisted delivery involves using a vacuum device to assist in the baby's delivery, and it can cause trauma to the birth canal, leading to increased bleeding risk in the mother.

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Correct Answer is C

Explanation

Choice A rationale:

The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.

Choice B rationale:

Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.

Choice D rationale:

Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.

A. Bluish discoloration of the hands and feet. B. Overlapping of the cranial bones. C. Forward and lateral positioning of the ears. D. Small, distended white sebaceous glands on the face.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.

Choice B rationale: Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.

Choice C rationale: Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.

Choice D rationale: Small, distended white sebaceous glands on the face (milia) are common in newborns and resolve on their own without intervention.

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A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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