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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

History and Physical A 36-year-old client who is gravida 5 para 5 (GSP5) 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.

Nurses’ Notes Received GSP5 client 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was assisted to the bathroom where she voided 150 mL clear yellow urine. Lochia rubra moderate with small clots, no foul odor noted. Fundus firm at umbilicus. Episiotomy edges well approximated, no redness, edema, drainage, or ecchymosis. No pain, redness or swelling in calves. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18 gauge peripheral IV in the left forearm at 125 mL/hr, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

gravida 5 para 5

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

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

client had a 4th degree laceration

Estimated blood loss was 600 mL after delivery

Lochia rubra moderate with small clots

Episiotomy edges well approximated

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing

The IV is patent, without redness or swelling

given an epidural for anesthesia that was effective

vital signs were stable

Answer and Explanation

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

Based on the client’s history and physical, the following areas increase the risk for postpartum hemorrhage:

Gravida 5 Para 5 (G5P5): Multiparity (having given birth 5 times) can increase the risk of postpartum hemorrhage due to uterine atony (lack of muscle tone) resulting from repeated stretching of the uterus.
Delivery of a 9 lb 1 oz (4.1 kg) baby: Macrosomia (large baby) can overstretch the uterus, increasing the risk of uterine atony and postpartum hemorrhage.
Labor for 25 hours and use of forceps for delivery: Prolonged labor and instrumental delivery can lead to uterine fatigue and atony, increasing the risk of postpartum hemorrhage.
4th degree laceration: Severe lacerations can lead to significant blood loss.
Estimated blood loss was 600 mL after delivery: This is a significant amount of blood loss and could indicate a risk for further hemorrhage.
Lochia rubra moderate with small clots: This could indicate ongoing blood loss.

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Correct Answer is C

Explanation

Choice A rationale

While a headache with sudden onset can be a symptom of various conditions, it is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice B rationale

Flat jugular vein distention (JVD) at 45 degrees is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice C rationale

An abnormal level of consciousness can be a sign of decreased cerebral perfusion, which can occur in a client with atrial fibrillation and a rapid ventricular rate. This is a critical finding that should be reported to the healthcare provider immediately.

Choice D rationale

Nausea with vomiting is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

A. Assign the newly hired UAP to clients who require the least complex level of care. B. Review the UAP’s skills checklist and experience with the person who hired the UAP. C. Ask the most experienced UAP on the team to partner with the newly hired UAP. D. Assess the newly hired UAP’s competency level by observing the UAP deliver care.

Correct Answer is D

Explanation

Choice A rationale

Assigning the newly hired UAP to clients who require the least complex level of care might not be the best approach. While it might seem logical to assign less complex cases to a new hire, this could limit the UAP’s opportunities for learning and growth.

Choice B rationale

Reviewing the UAP’s skills checklist and experience with the person who hired the UAP is an important step, but it might not be enough to ensure adequate care for all clients. The skills and experiences listed on a checklist might not fully reflect the UAP’s actual abilities in a real-world setting.

Choice C rationale

Asking the most experienced UAP on the team to partner with the newly hired UAP could be beneficial for mentorship and guidance. However, this might not be the most efficient use of resources, especially if the experienced UAP has to spend a significant amount of time supervising the new hire.

Choice D rationale

Assessing the newly hired UAP’s competency level by observing the UAP deliver care is the most effective way to ensure adequate care for all clients. This allows the nurse to directly evaluate the UAP’s skills and abilities in a real-world setting, and to provide immediate feedback and guidance as needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

A newly recruited unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.What intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is D

Explanation

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After receiving a change of shift report for patients on a medical-surgical unit, which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

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