The nurse is reviewing the client’s chart.
Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.
Client was middle aged and married.
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.
Client was middle aged
forceps were used to assist with the delivery
client had a 4th degree laceration
She was in labor for 25 hours
The Correct Answer is ["B","C","D"]
Choice A rationale
Age of the client is not a significant risk factor for postpartum hemorrhage. While age can influence overall health and pregnancy complications, it is not directly linked to an increased risk of postpartum hemorrhage. Therefore, the age of the client, in this case, does not increase the risk for postpartum hemorrhage.
Choice B rationale
The use of forceps during delivery can increase the risk of postpartum hemorrhage. Forceps delivery is an assisted delivery method which can cause trauma to the birth canal, leading to increased bleeding after delivery. In this case, the client had a forceps-assisted delivery, which could increase her risk for postpartum hemorrhage.
Choice C rationale
A 4th degree laceration is a severe tear that occurs during delivery, extending to the anal sphincter and rectal mucosa. This type of laceration can lead to significant blood loss and increase the risk of postpartum hemorrhage. In this case, the client had a 4th degree laceration, which increases her risk for postpartum hemorrhage.
Choice D rationale
A long labor duration can increase the risk of postpartum hemorrhage. Prolonged labor can lead to uterine atony, a condition where the uterus does not contract properly after delivery, leading to increased bleeding. In this case, the client was in labor for 25 hours, which could increase her risk for postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Postpartum hemorrhage is a serious complication that can occur after a vaginal delivery. Methylergonovine is a medication that stimulates the uterine contractions and reduces the bleeding from the placental site.
Choice B rationale
Postpartum infection is another possible complication after a vaginal delivery, but methylergonovine is not used to prevent it. Antibiotics are the main treatment for postpartum infections.
Choice C rationale
Thromboembolic events are blood clots that can form in the veins or arteries and cause life-threatening conditions such as pulmonary embolism or stroke. Methylergonovine is not used to prevent thromboembolic events. Anticoagulants are the main prevention for thromboembolic events.
Choice D rationale
Hypertension is high blood pressure that can cause damage to the organs and increase the risk of cardiovascular diseases. Methylergonovine is not used to prevent hypertension. In fact, methylergonovine can cause hypertension as a side effect and should be used with caution in clients with high blood pressure. Antihypertensives are the main treatment for hypertension.
Correct Answer is B
Explanation
Choice A rationale
Vaginal discharge is not a finding that indicates preeclampsia. Vaginal discharge is a normal occurrence during pregnancy, as the cervix and vaginal walls soften and produce more mucus. Vaginal discharge can also indicate infections, such as yeast or bacterial vaginosis, which are not related to preeclampsia.
Choice B rationale
Elevated blood pressure is a finding that indicates preeclampsia. Preeclampsia is a condition that causes high blood pressure and proteinuria in pregnant women after 20 weeks of gestation. Preeclampsia can lead to serious complications, such as eclampsia, HELLP syndrome, and placental abruption, which can endanger the mother and the fetus. The nurse should monitor the client's blood pressure and report any readings above 140/90 mm Hg.
Choice C rationale
Joint pain is not a finding that indicates preeclampsia. Joint pain is a common complaint during pregnancy, as the hormones and weight gain cause changes in the joints and ligaments. Joint pain can also indicate other conditions, such as arthritis, gout, or lupus, which are not related to preeclampsia.
Choice D rationale
Increased urine output is not a finding that indicates preeclampsia. Increased urine output is a normal occurrence during pregnancy, as the growing uterus puts pressure on the bladder and the kidneys filter more blood. Increased urine output can also indicate diabetes, urinary tract infection, or diuretic use, which are not related to preeclampsia.
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