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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This statement is correct. It is recommended that newborns be breastfed 8 to 12 times per day, which is about every 2 to 3 hours.
Choice B rationale
Supplementing with formula after breastfeeding is not typically recommended unless there is a medical reason. Supplementing can interfere with the supply and demand process that increases milk supply.
Choice C rationale
Using plastic-lined breast pads can trap moisture and exacerbate sore nipples. It is recommended to use 100% cotton breast pads and to change them frequently to keep the nipples dry.
Choice D rationale
While staying hydrated is important for overall health, there is no definitive evidence that drinking more water will increase milk supply. However, some mothers find that staying well- hydrated helps with their overall comfort and well-being during breastfeeding.
Correct Answer is D
Explanation
Choice A rationale
While male condoms are a popular method of contraception due to their accessibility and ease of use, they are not the most reliable method. They have a higher failure rate compared to other methods, particularly if not used correctly or consistently.
Choice B rationale
Oral contraceptives are more reliable than male condoms, but they require consistent daily use and can be affected by other factors such as certain medications or vomiting/diarrhea.
Choice C rationale
A diaphragm with spermicide is a barrier method of contraception that is less reliable than hormonal methods or intrauterine devices. It also requires correct placement and use with every act of intercourse.
Choice D rationale
An intrauterine device (IUD) is one of the most reliable methods of contraception. Once inserted by a healthcare provider, it provides long-term, reversible contraception without requiring daily adherence.
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