The nurse has reviewed the patient’s chart.
The nurse recognizes that this patient is hemorrhaging due to which condition?

Uterine atony

Wound dehiscence

Infection

Hemorrhage

Answer and Explanation

The Correct Answer is A

Choice A rationale

Uterine atony refers to a condition where the uterus fails to contract sufficiently during and after childbirth. This lack of contraction can lead to excessive bleeding, also known as postpartum hemorrhage. This is because the contractions of the uterus after delivery help to compress the blood vessels and prevent bleeding. Therefore, uterine atony can cause a patient to hemorrhage.

Choice B rationale

Wound dehiscence refers to a surgical complication where an incision reopens either internally or externally. It can cause pain, infection, and organ protrusion. However, it is not directly associated with hemorrhaging.

Choice C rationale

Infection refers to the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. While severe infections can lead to sepsis and disseminated intravascular coagulation, which can cause bleeding, they do not directly cause hemorrhaging.

Choice D rationale

Hemorrhage is a symptom, not a condition. It refers to excessive bleeding which can occur due to various conditions, including uterine atony.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.

Choice B rationale

A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.

Choice C rationale

Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.

Choice D rationale

A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.

A. hospitalized for 2 weeks B. initially in the intensive care unit and has been moved to the surgical floor C. pain is rated as 2 on a 0 to 10 pain scale D. client has requested sleeping medication for the night E. keeps having distressing thoughts and memories about the house collapsing F. Now I can’t seem to get out of this funk I am in G. expressed a preference for a quieter area of the unit

Correct Answer is ["D","E","F","G"]

Explanation

Based on the provided information, the following aspects of the assessment require urgent attention:

The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.

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The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

Correct Answer is ["A","B"]

Explanation

Correct Answer is ["D","E","F","G"]

Explanation

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The nurse has reviewed the patient’s chart.
The nurse recognizes that this patient is hemorrhaging due to which condition?