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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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

A. The patient was able to sleep through the night. B. The patient’s left arm is warm to touch. C. The patient’s left shoulder and collarbone are symmetric. D. The patient has no desire to eat breakfast.

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

Explanation

Choice A rationale

The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.

Choice B rationale

The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.

Choice C rationale

The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.

Choice D rationale

The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

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

Explanation

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.Which action should the nurse take next?

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

A patient undergoing radiation treatment for laryngeal cancer has developed xerostomia and mucositis, leading to an imbalance in nutritional intake.What is the most likely reason for this issue?