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
Maternal serum alpha-fetoprotein (MSAFP) is a protein produced by the fetal liver and yolk sac. It crosses the placenta and enters the maternal blood. High levels of MSAFP may indicate neural tube defects such as spina bifida or anencephaly in the fetus. Low levels of MSAFP may indicate chromosomal abnormalities such as Down syndrome or trisomy 18 in the fetus.
Choice B rationale
Fetal lung maturity is not assessed by MSAFP. Fetal lung maturity is assessed by measuring the lecithin/sphingomyelin (L/S) ratio or the phosphatidylglycerol (PG) level in the amniotic fluid. These tests are usually done in the third trimester of pregnancy.
Choice C rationale
Rh incompatibility is not identified by MSAFP. Rh incompatibility is a condition where the mother has Rh-negative blood and the fetus has Rh-positive blood. This can cause hemolytic disease of the newborn (HDN) if the mother develops antibodies against the fetal red blood cells. Rh incompatibility is identified by testing the mother's blood type and antibody screen, and the father's blood type if available.
Choice D rationale
MSAFP does not assess various markers of fetal well-being. MSAFP is only one of the markers that can be used in the maternal serum screening test, which is also known as the quad screen or the triple screen. The other markers are human chorionic gonadotropin (hCG), unconjugated estriol (uE3), and inhibin A. These markers can help detect the risk of certain birth defects or genetic disorders in the fetus, but they are not definitive tests. Fetal well-being can be assessed by other tests such as fetal movement count, nonstress test, biophysical profile, or Doppler ultrasound.
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.
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