Which client is at greatest risk for early postpartum hemorrhage (PPH)?
Primigravida in spontaneous labor with preterm twins
Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
Woman with severe preeclampsia on magnesium sulfate whose labor is being induced
The Correct Answer is C
Choice A reason: Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.
Choice B reason: Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.
Choice C reason: Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.
Choice D reason: Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: To stay with the client and call for help is the highest priority during a seizure, because it ensures the safety of the client and the fetus, and allows the nurse to monitor the vital signs and fetal heart rate. The nurse should also protect the client from injury and turn the client to the side to prevent aspiration.
Choice B reason: To suction the mouth to prevent aspiration is not the highest priority during a seizure, because it can cause more harm than good. Suctioning can stimulate the gag reflex and increase the risk of vomiting and aspiration. It can also injure the oral mucosa and trigger another seizure.
Choice C reason: To administer oxygen by mask is not the highest priority during a seizure, because it may not be effective or necessary. Oxygen administration can be difficult or impossible during a seizure, and it may not improve the oxygen saturation or fetal outcome. Oxygen should only be given if hypoxia is confirmed by pulse oximetry or arterial blood gas analysis.
Choice D reason: To insert an oral airway is not the highest priority during a seizure, because it can be dangerous and contraindicated. Inserting an oral airway can damage the teeth and tongue, and increase the risk of vomiting and aspiration. It can also provoke another seizure or laryngospasm. An oral airway should only be used if the client is unconscious and has no gag reflex.
Correct Answer is C
Explanation
Choice A reason: To call for an immediate magnesium sulfate level is not the immediate action that the nurse should take, as it is a diagnostic test that requires a blood sample and a laboratory analysis, which can take time and delay the treatment. The nurse should first stop the infusion and notify the provider, as the client is showing signs of magnesium sulfate toxicity, which is a life-threatening condition that can cause respiratory depression, cardiac arrest, or coma.
Choice B reason: To prepare to administer hydralazine is not the immediate action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the blood pressure and the fetal status. Hydralazine is an antihypertensive drug that lowers the blood pressure and prevents the complications of severe preeclampsia, such as eclampsia, stroke, or organ damage. However, the client's blood pressure is not very high and is not the main problem at the moment.
Choice C reason: To discontinue the magnesium sulfate infusion is the immediate action that the nurse should take, as it is the first and most important intervention that can reverse the effects of magnesium sulfate and restore the neuromuscular function and the respiratory rate. Magnesium sulfate is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, but it can also cause toxicity if the dose is too high or the infusion is too fast.
Choice D reason: To administer oxygen is not the immediate action that the nurse should take, as it is a supportive intervention that improves the oxygen delivery to the tissues and organs, but does not address the underlying cause of the respiratory depression, which is the magnesium sulfate toxicity. The nurse should administer oxygen only after stopping the infusion and assessing the oxygen saturation and the respiratory status.
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