When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

Thromboembolism

Cervical laceration

Hemorrhoids

Hemorrhage

Answer and Explanation

The Correct Answer is D

Hemorrhage. This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.

Choice A is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.

Choice B is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.

Choice C is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.

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Correct Answer is C

Explanation

ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.

Choice A is not correct because the client's milk will come in regardless of nursing frequency.

Choice B is not correct because the client's temperature is within normal limits.

Choice D is not correct because there is no indication of an increase in IV fluids.

A. Change in lochia from red to white B. Fatigue and irritability C. Fever D. Contractions

Correct Answer is C

Explanation

Fever. This is because fever is a sign of infection, which is a common and potentially serious postpartum complication. Infection can affect various parts of the body, such as the uterus (endometritis), the bladder (cystitis), the breast (mastitis), the wound (wound infection), or the blood (sepsis). Infection can cause symptoms such as fever, chills, pain, foul-smelling discharge, redness, swelling, or warmth at the site of infection.

Choice A is not correct because the change in lochia from red to white is not a sign of postpartum complication. Lochia is the vaginal discharge that occurs after childbirth. It changes color and amount over time, from red to pink to brown to yellow to white. This is a normal process of healing and does not indicate a problem unless the lochia is foul-smelling, heavy, or contains large clots³.

Choice B is not correct because fatigue and irritability are not signs of postpartum complications. Fatigue and irritability are common feelings after childbirth due to hormonal changes, sleep deprivation, physical recovery, and emotional adjustment. They do not necessarily indicate a problem unless they are severe or persistent and interfere with daily functioning or bonding with the baby.

Choice D is not correct because contractions are not signs of postpartum complication. Contractions are normal after childbirth and help the uterus shrink back to its pre-pregnancy size. They are usually mild and subside within a few days. They may be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine contractions.

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When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

Correct Answer is C

Explanation

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should interpret this finding as which of the following?

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent?

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.