Share This Link

Postpartum infection, such as puerperal sepsis, typically presents with fever, chills, uterine tenderness, and foul-smelling lochia. While the client is experiencing discomfort, there is no mention of fever or purulent discharge. The primary signs observed relate to excessive bleeding and uterine displacement, not infectious processes. A normal temperature range is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Endometritis is an infection of the uterine lining, often occurring postpartum. Symptoms include fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia. The client's symptoms of a boggy fundus, heavy bleeding, and fundal deviation are more indicative of a bleeding issue rather than an infection confined to the endometrium. White blood cell count would typically be elevated in infection, with a normal range being 4,500 to 11,000 cells/mm³.

A urinary tract infection (UTI) is characterized by dysuria, urgency, frequency, and sometimes hematuria. While the client reports an urge to urinate and voided a small amount, the primary and more concerning findings are related to the uterine status and excessive bleeding, which are not typical signs of a UTI. A urine culture would show bacterial growth in a UTI, with a normal urinalysis showing no or few bacteria.

Uterine inversion is a rare but severe complication where the uterus turns inside out, often presenting with sudden, severe pain, vaginal hemorrhage, and a mass protruding from the vagina. While hemorrhage is present, the description of the fundus being boggy and 2 finger breaths above the umbilicus, rather than inverted or prolapsed, makes uterine inversion less likely. The primary issue is uterine atony leading to blood loss.

Patterned breathing techniques involve conscious control of respiratory rate and depth, which can redirect attention and promote relaxation. This cognitive distraction reduces the perception of pain by engaging higher cortical centers, thus modulating pain signals transmitted via the spinothalamic tracts. However, it does not directly address the localized pressure associated with back labor.

Effleurage involves light, circular stroking of the abdomen. This gentle cutaneous stimulation activates large-diameter afferent nerve fibers, which, according to the gate control theory of pain, can inhibit the transmission of noxious stimuli by smaller-diameter fibers in the spinal cord. While soothing, it may not provide sufficient counter-pressure for intense back labor.

Guided imagery involves directing the client to focus on pleasant mental images to divert attention from pain. This cognitive behavioral strategy can activate descending inhibitory pathways from the brainstem, releasing endogenous opioids and serotonin, thereby modulating pain perception. However, it may not be as effective for the specific, intense pressure of back labor.

Placing the newborn under a radiant warmer is crucial for thermoregulation, preventing cold stress, which can lead to increased metabolic rate and oxygen consumption. While important, assessing for potential airway compromise due to meconium aspiration takes immediate precedence over maintaining temperature, as respiratory status is critical for survival.

Providing tactile stimulation can encourage respiratory effort in a depressed newborn. However, in the presence of meconium-stained amniotic fluid, initial assessment of the airway and the need for suctioning must occur before stimulating the newborn to breathe deeper, which could potentially draw meconium further into the lungs.

Initiating skin-to-skin contact promotes maternal-newborn bonding and can stabilize the newborn's temperature and blood glucose. While beneficial, it is not the immediate priority when meconium is present. Airway management and respiratory stabilization must be ensured before initiating skin-to-skin contact to prevent complications from meconium aspiration.

While a cesarean birth is often indicated for breech presentations, especially with ruptured membranes, it is not the immediate first action. The priority is to assess fetal well-being, specifically ruling out umbilical cord prolapse, as this is an acute emergency that requires immediate intervention to prevent fetal hypoxia and mortality, prior to surgical preparation.

Assessing the color, amount, and odor of the amniotic fluid provides information about potential infection or meconium presence, which are important data points. However, the immediate life-threatening complication with ruptured membranes and breech presentation is umbilical cord prolapse, making fetal heart tone assessment a more urgent priority.

Performing a Nitrazine test confirms the rupture of membranes, but the client has already reported "my water just broke.”. While a confirmatory test, it is not the immediate priority. The critical concern is the potential for umbilical cord prolapse, which directly impacts fetal oxygenation and requires immediate assessment via fetal heart tones.

A second-degree perineal laceration causes localized pain and discomfort, potentially leading to a cautious gait. While this can affect mobility, it does not inherently present the same level of tripping hazard or systemic physiological changes like orthostatic hypotension that are associated with an indwelling catheter, making the fall risk comparatively lower.

Saturating a perineal pad every 5 to 6 hours indicates a normal lochial flow. Excessive bleeding (saturating a pad in less than an hour) would be a significant risk factor for hypovolemia and subsequent orthostatic hypotension, thus increasing fall risk. Normal flow, however, does not directly contribute to an increased fall risk.

Breast engorgement causes discomfort and fullness in the breasts, which can limit arm movement and potentially interfere with comfortable positioning. While uncomfortable, breast engorgement itself does not typically lead to systemic physiological changes like orthostatic hypotension or create physical impediments that directly increase the risk of a fall.

Consuming milk with iron supplements significantly inhibits iron absorption due to the high calcium content in milk. Calcium competes with iron for absorption sites in the small intestine, forming insoluble complexes that reduce the bioavailability of iron. This would counteract the intended therapeutic effect of the iron supplementation, leading to suboptimal iron levels.

Doubling an iron dose can lead to iron toxicity, which is dangerous, especially during pregnancy. Excessive iron intake can cause gastrointestinal distress, liver damage, and metabolic acidosis. Adhering to the prescribed dosage is crucial for safe and effective supplementation, preventing adverse effects while achieving therapeutic iron levels.

Vitamin K is essential for blood coagulation, but taking 100 milligrams daily during pregnancy without a specific medical indication is excessive and potentially harmful. The normal recommended daily allowance for vitamin K during pregnancy is much lower, around 90 micrograms. High doses could interfere with anticoagulant medications or have unknown fetal effects.

During labor, the body experiences physiological stress and an inflammatory response, leading to an increase in white blood cell count. This leukocytosis is a normal physiological adaptation to the physical demands of labor and tissue remodeling, not a decrease. A normal WBC count is typically 4,500-11,000 cells/µL, and it can rise to 15,000-20,000 cells/µL during labor.

The pain and physiological stress of labor typically cause an increase in respiratory rate, not a decrease. The body tries to compensate for the increased metabolic demand and oxygen consumption by increasing ventilation. A decrease in respiratory rate would be an unexpected and potentially concerning finding, indicating respiratory depression. A normal respiratory rate is 12-20 breaths per minute.

While slight fluctuations can occur, a significant decrease in temperature is not an expected finding during labor. The metabolic activity and physical exertion of labor can slightly elevate body temperature, or it may remain stable. A decrease in temperature could indicate hypothermia or a systemic issue, which is not a normal physiological response to labor. A normal temperature is 36.5-37.5°C.

Monitoring blood pressure every 30 minutes following epidural placement is insufficient. Epidural anesthesia often causes sympathetic blockade, leading to vasodilation and a rapid drop in blood pressure. Frequent monitoring, typically every 2-5 minutes initially, is critical to detect and manage hypotension promptly, ensuring adequate placental perfusion.

Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is generally not indicated as a routine prophylactic measure. Oxygen supplementation is typically reserved for instances where maternal oxygen saturation is low or there is fetal distress, not as a standard pre-epidural intervention for normoxic clients.

Repositioning the client every 2 hours following epidural placement is not frequent enough. To promote even distribution of the anesthetic and prevent prolonged pressure on specific areas, the client should be repositioned more frequently, typically every 30-60 minutes, from side to side, especially during active labor.