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
A. Provide humidified oxygen.
Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.
B. Perform chest physiotherapy prior to suctioning.
Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.
Correct Answer is B
Explanation
Choice A rationale
Amniotic fluid in the vaginal vault is not a definitive sign of labor. It indicates that the membranes have ruptured, which can occur before or during labor. However, some clients may not have their membranes ruptured until the late stages of labor or during delivery.
Choice B rationale
Cervical dilation is a definitive sign of labor. It indicates that the cervix is opening and thinning to allow the passage of the fetus. Cervical dilation is measured in centimeters from 0 to 10, with 10 being fully dilated and ready for delivery.
Choice C rationale
Brownish vaginal discharge is not a definitive sign of labor. It may indicate the presence of the bloody show, which is the mucus plug that seals the cervix during pregnancy. The bloody show may be expelled before or during labor, but it does not necessarily mean that labor has started.
Choice D rationale
Report of pain above the umbilicus is not a definitive sign of labor. It may indicate the presence of Braxton Hicks contractions, which are irregular and painless contractions that occur throughout pregnancy. They are also known as false labor contractions, as they do not cause cervical dilation or effacement.
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