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Exhibits

The nurse is reviewing the clients' chart.

Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.

36-year-old client who is gravida 5, para 5, transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine just prior to delivery. Her spouse was at the bedside for delivery and appeared supportive. Blood type A+. Estimated blood loss was 600 ml. after delivery.

gravida 5, para 5

delivery of a 9 lb 1 oz (4.1 kg) female

She was in labor for 25 hours and forceps were used to assist with the delivery

4th degree laceration

her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine

Estimated blood loss was 600 ml. after delivery.

She was given an epidural for anesthesia that was effective.

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

36-year-old client who is gravida 5, para 5, transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine just prior to delivery. Her spouse was at the bedside for delivery and appeared supportive. Blood type A+. Estimated blood loss was 600 ml. after delivery.

Rationale:

Gravida 5, Para 5 (G5P5): Having multiple pregnancies can increase the risk of uterine atony and hemorrhage after delivery. Each subsequent pregnancy may carry a higher risk for complications.

Prolonged Labor (25 hours): Prolonged labor is associated with increased uterine fatigue and can lead to uterine atony, which is a primary cause of PPH.

Delivery of a 9 lb 1 oz (4.1 kg): Macrosomia can lead to complications during birth, such as maternal and/or fetal trauma, which in turn may increase the likelihood of PPH.

Use of Forceps: The use of forceps during delivery can lead to trauma and lacerations, which may contribute to increased bleeding, especially with a 4th degree laceration.

4th Degree Laceration: This type of laceration extends through the anal sphincter and can lead to significant bleeding. It also increases the risk of infection and other complications.

Estimated Blood Loss of 600 mL: While this is within the normal range for delivery, it may be concerning in the context of the other risk factors and warrants careful monitoring for additional bleeding.

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Correct Answer is A

Explanation

A. Explaining the physiological signs of imminent death helps prepare the spouse and family for what to expect, allowing them to gather as needed.

B. While discussing the client’s health status may be supportive, it does not directly address the spouse’s request for understanding signs of impending death.

C. Gathering information about how long it will take for the children to arrive is important but secondary to providing the spouse with information about impending signs of death.

D. While reassuring the spouse is important, it may not provide the immediate information they seek about recognizing the signs of dying.

A. Measure the girth of the client's lower abdomen. B. Palpate the area above the pubic symphysis. C. Auscultate an area six inches below the umbilicus. D. Observe the appearance of the client's urine.

Correct Answer is B

Explanation

A. Measuring the girth of the lower abdomen can provide some information but is not the most direct assessment for urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distension, which is a direct indicator of urinary retention.

C. Auscultating an area six inches below the umbilicus is not a standard assessment technique for urinary retention.

D. Observing the appearance of the urine can provide information about urinary output but does not directly assess for retention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks how to know that the spouse's death is imminent because their two adult children want to be there when the client dies. Which is the best response by the nurse?

Correct Answer is A

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is B

Explanation

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