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A nurse on a postpartum unit is caring for a client.

Exhibits
For each finding, click to specify if the finding increases the client's risk for uterine atony or infection.

A.

Polyhydramnios

B.

Prolonged rupture of membranes

C.

Prenatal anemia

D.

High parity

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Rationale:

  • Polyhydramnios: Excess amniotic fluid can overdistend the uterus, reducing its ability to contract effectively after delivery, which increases the risk of uterine atony and postpartum hemorrhage.
  • Prolonged rupture of membranes: A long duration of ruptured membranes increases the risk of bacteria ascending into the uterus, which can lead to endometritis and systemic infection postpartum.
  • Prenatal anemia: Low hemoglobin levels reduce oxygen delivery to tissues and impair the immune response, increasing susceptibility to infections such as endometritis or wound infection after cesarean birth.
  • High parity: Multiple pregnancies can cause stretching and weakening of the uterine muscle, which may result in inadequate contraction postpartum, predisposing the client to uterine atony.


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Related Questions

Correct Answer is ["2.5"]

Explanation

Calculation:

Desired dose = 20 mg.

Available concentration = 40 mg / 5 mL

= 8 mg/mL.

  • Calculate the volume to administer in milliliters (mL).

Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)

= 20 mg / 8 mg/mL

= 2.5 mL.

Correct Answer is ["A","B","D","E"]

Explanation

Rationale for correct choices:

  • Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and renal complications. Immediate assessment and fluid management are necessary to prevent further physiological deterioration.
  • Heart rate: A heart rate of 120/min is tachycardic. This can be caused by dehydration, stimulant effects of mania, or other underlying medical issues. It requires prompt monitoring and intervention to prevent cardiovascular compromise.
  • Sleep pattern: The client has not slept for 2 days, which increases the risk for physical exhaustion, worsening psychiatric symptoms, and impaired judgment. Sleep deprivation in the context of mania requires immediate attention to stabilize the client.
  • Hallucinations: The client reports listening to unseen others, indicating auditory hallucinations. This can pose a risk for self-harm or unsafe behaviors, and immediate psychiatric assessment and intervention are warranted.

Rationale for incorrect choice:

  • Hygiene: While the client’s hair and clothing are unclean, indicating self-care deficits, this is not an immediate threat to physiological stability. It is important for overall care planning but does not require urgent intervention compared to dehydration, tachycardia, sleep deprivation, or hallucinations.

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