Which assessment findings may cause the nurse to suspect a brachial plexus injury?

Choice A:

Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.

Choice B:

Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.

Choice C:

Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.

Choice D:

Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.

Choice E:

Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.

Choice A reason:

Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage. It is the most common cause of postpartum hemorrhage, accounting for up to 80 percent of cases. Risk factors for uterine atony include large or multiple babies, prolonged or rapid labor, overdistended uterus, use of oxytocin or magnesium sulfate during labor, and previous history of uterine atony.

Choice B reason:

Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery. It can affect the uterus (endometritis), the bladder (cystitis), the kidneys (pyelonephritis), the breast (mastitis), or the wound (cesarean section or episiotomy).

Symptoms include fever, chills, malaise, foul-smelling lochia, pelvic pain, and wound redness or drainage. Risk factors for puerperal infection include cesarean delivery, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, retained placental fragments, and poor hygiene.

Choice C reason:

Retained placental fragments are pieces of the placenta that remain in the uterus after delivery. They can cause postpartum hemorrhage, infection, or delayed involution of the uterus. Symptoms include heavy or prolonged bleeding, fever, abdominal pain, and an enlarged uterus. Risk factors for retained placental fragments include placenta previa, placenta accrete, manual removal of the placenta, and incomplete examination of the placenta after delivery.

Choice D reason:

Thrombophlebitis is the inflammation and clotting of a vein, usually in the legs or pelvis. It can cause pain, swelling, redness, and warmth in the affected area. It can also lead to pulmonary embolism if the clot breaks off and travels to the lungs. Risk factors for thrombophlebitis include pregnancy and the postpartum period, cesarean delivery, obesity, smoking, dehydration, immobility, varicose veins, and inherited or acquired clotting disorders.