A nurse is caring for a client who is 36 hours postpartum.

The nurse’s notes indicate the following: Breasts are soft, warm, and tender to touch. The client denies any nipple or breast discomfort.

The fundus is boggy, located 1 cm above the umbilicus and deviated to the right. The fundus becomes firm with massage.

The client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10. The perineal pad shows a moderate amount of lochia rubra.

The client has been given an analgesic.

After reviewing the information in the client’s medical record, which of the following complications poses the greatest risk for the client?

Postpartum hemorrhage

Infection

Thrombophlebitis

Pulmonary embolism

Answer and Explanation

The Correct Answer is A

Choice A rationale

Postpartum hemorrhage is a serious condition characterized by heavy bleeding after childbirth. In the scenario described, the nurse’s notes indicate that the client’s fundus is boggy and located 1 cm above the umbilicus, which becomes firm with massage. This could be a sign of uterine atony, a leading cause of postpartum hemorrhage. Additionally, the client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10, and the perineal pad shows a moderate amount of lochia rubra. These are all signs that could indicate a postpartum hemorrhage.

Choice B rationale

While infection is a possible postpartum complication, the symptoms provided do not strongly indicate an infection. Symptoms of a postpartum infection typically include soreness, tenderness, or swelling of the belly or abdomen, chills, pain while urinating or during sex, abnormal vaginal discharge that has a bad smell or blood in it, and a general feeling of discomfort or unwellness.

Choice C rationale

Thrombophlebitis is a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow. It commonly occurs in the legs but can occur elsewhere in the body. The symptoms include swelling of the affected area, redness of the affected area, tenderness of the affected area, warmth around the affected area, and pain. However, the symptoms provided do not strongly indicate thrombophlebitis.

Choice D rationale

Pulmonary embolism is a serious condition that occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung. Symptoms can include shortness of breath or chest pain. However, the symptoms provided do not strongly indicate a pulmonary embolism.

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Correct Answer is D

Explanation

Choice A rationale

Gravida 4 Para 3 at 33 weeks of gestation is not an alarming finding. It simply indicates that the woman is pregnant for the fourth time and has had three previous deliveries. This is a normal part of the woman’s obstetric history and does not need to be reported to the provider.

Choice B rationale

Allergies, such as a sulfa allergy, are important to note in the patient’s medical history. However, unless the patient is being prescribed a medication that she is allergic to, this information does not need to be urgently reported to the provider.

Choice C rationale

A height of 165 cm (66 in), weight of 82 kg (180 lb), and BMI of 30.6 are all within normal ranges for a pregnant woman. These measurements are part of routine prenatal care and do not need to be urgently reported to the provider.

Choice D rationale

A weight gain of 32 kg (7 lb) over the last 2 weeks is concerning. Rapid weight gain can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. This should be reported to the provider immediately.

A. Fetal heart rate (FHR) B. Temperature C. Respiratory rate D. Bowel sounds

Correct Answer is C

Explanation

The correct answer is choice C: Respiratory rate.

Choice A rationale:

Fetal heart rate (FHR) is an important assessment for clients experiencing preterm labor, but it is not the priority assessment when administering magnesium sulfate. FHR monitoring is crucial to ensure fetal well-being but is not directly related to the potential adverse effects of magnesium sulfate.

Choice B rationale:

Temperature is an essential assessment parameter, but it is not the priority in this case. Magnesium sulfate administration can cause adverse effects, particularly on the respiratory system, which should be closely monitored.

Choice C rationale:

Respiratory rate is the correct choice because respiratory rate is a priority assessment when administering magnesium sulfate. The drug can cause respiratory depression and other respiratory complications, so monitoring the respiratory rate is essential to ensure the client's safety.

Choice D rationale:

Bowel sounds are not a priority assessment for a client receiving magnesium sulfate. While gastrointestinal side effects can occur with magnesium sulfate use, respiratory assessments take precedence.

In conclusion, the priority nursing assessment for a client receiving magnesium sulfate is the respiratory rate due to the potential respiratory complications associated with the drug. Monitoring respiratory function closely can help prevent adverse outcomes and ensure the client's safety during treatment.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an antepartum clinic is caring for a client who is pregnant. Select the assessment findings the nurse should report to the provider.

Correct Answer is D

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is C

Explanation

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