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Rationale for Correct Choices:

• 36-year-old client who is gravida 5, para 5 (G5P5): The client is a multipara, which increases the risk of uterine atony due to difficulty with uterine contractions or postpartum hemorrhage as a result of overstretched uterine muscles.
• Transferred to the postpartum unit 1 hour after delivery of a 9 lb. 1 oz (4.1 kg) female: Macrosomia increases the likelihood of trauma during delivery, including lacerations and uterine atony increasing the risk for postpartum hemorrhage.
• In labor for 25 hours: Prolonged labor increases the risk of uterine atony, where the uterus struggles to contract after delivery. This can lead to an increased risk of postpartum hemorrhage as the uterus fails to close off blood vessels effectively.
• Forceps were used to assist with the delivery: Forceps-assisted deliveries can cause trauma to the birth canal, cervix, or perineum, leading to increased bleeding. This traumatic delivery can also contribute to uterine atony, raising the risk of postpartum hemorrhage.
• 4th degree laceration: A 4th degree laceration involves extensive damage to the perineum and anal sphincter, increasing bleeding risk. This severe injury requires surgical repair and is a known risk factor for postpartum hemorrhage due to the size and depth of the tear.
• Estimated blood loss was 600 mL after delivery: Blood loss of 600 mL after delivery, although within the normal range for some vaginal deliveries, is considered a moderate risk factor. It may indicate ongoing bleeding or inadequate uterine contraction, both contributing to postpartum hemorrhage risk.
• Macrosomic baby (9 lb 1 oz): A larger-than-normal baby (macrosomia) increases the likelihood of a difficult delivery, trauma to the birth canal, and uterine atony. These factors, combined with a prolonged labor, raise the risk of postpartum hemorrhage.

Rationale for Incorrect Choices:

• Epidural anesthesia: The use of epidural anesthesia provides pain relief but does not directly increase the risk of postpartum hemorrhage. While epidurals may delay mobilization, they do not interfere with uterine tone or bleeding.
• Vital signs were stable: Stable vital signs, including normal blood pressure, respiratory rate, and heart rate, indicate that the client is not in acute distress or hemorrhaging severely at this time.

Rationale for Correct Choices:

• Venous thromboembolism: Prolonged labor, forceps use, and immobility after delivery increase the risk of venous thromboembolism. These factors hinder circulation and elevate clotting risks, especially with epidural anesthesia.
• Postpartum hemorrhage: Prolonged labor, forceps delivery, and a 4th degree laceration contribute to uterine atony and trauma, increasing the likelihood of postpartum hemorrhage. The client’s blood loss further supports this risk.

Rationale for Incorrect Choices:

• Preeclampsia: The client’s blood pressure is normal, and there are no symptoms of preeclampsia such as proteinuria or severe hypertension. Therefore, preeclampsia is not a concern.
• Seizures: There is no history of eclampsia or any neurological symptoms in the client’s presentation. Her vital signs are stable, further reducing the risk of seizures.
• Wound dehiscence: The 4th degree laceration appears well approximated with no signs of infection or healing issues. Thus, wound dehiscence is not a current risk.

Rationale for Correct Choices:

• At risk of hemorrhage: Signs of postpartum hemorrhage, including a boggy fundus, excessive bleeding (saturated pad within 15 minutes), and a drop in blood pressure. These are all indications of uterine atony, which is a major cause of postpartum hemorrhage.
• Boggy fundus with a shift to the right: A boggy fundus is a hallmark of uterine atony, where the uterus does not contract effectively to stop bleeding. The shift to the right suggests that the uterus is not in its optimal position, potentially due to retained products or a full bladder, both of which can worsen hemorrhage.

Rationale for Incorrect Choices:

• Moderate lochia rubra with small clots: Lochia rubra with small clots in the first few hours post-delivery is generally expected and not immediately concerning unless there is significant soaking of pads or foul-smelling discharge.
• At risk for infection: While the client does have a 4th-degree laceration, there are no signs of infection, such as fever, redness, swelling, or purulent discharge. The focus here should be on the risk of hemorrhage due to the clinical presentation.
• In pain: While the client reports mild pain (4/10), it is not the most critical issue at this stage. The client's condition is more concerning due to the signs of hemorrhage and uterine atony. Pain management is not an immediate priority compared to controlling blood loss.
• Genital tract trauma: The signs of hemorrhage, such as a boggy fundus and rapid bleeding, are more pressing at this point than the concern for genital tract trauma, as there is no indication of active infection or dehiscence at this time.

Rationale for Correct Choices:

• Oxygen saturation of 89%: An oxygen saturation of 89% is below the normal range (95-100%), indicating hypoxemia. This requires immediate follow-up as it suggests inadequate oxygenation, which could be due to respiratory or circulatory complications.
• Several deep breaths suggest the patient is trying to compensate for the low oxygen levels by increasing her tidal volume, which may be a sign of respiratory distress or insufficient oxygenation.
• Blood pressure 90/62 mm Hg: A drop in blood pressure from the previous reading (102/72 mm Hg) to 90/62 mm Hg could indicate hypovolemia, possibly due to blood loss. This warrants immediate attention to assess the cause, particularly in the context of the client’s risk for hemorrhage.
• Pad is saturated with blood: A saturated pad in 15 minutes indicates excessive blood loss, which is concerning for postpartum hemorrhage. This finding requires prompt assessment to manage and treat any ongoing bleeding and prevent further complications.
• Boggy fundus 1 cm above umbilicus: A boggy fundus is a sign of uterine atony, where the uterus fails to contract effectively, leading to excessive bleeding. Immediate intervention, such as fundal massage, is needed to help the uterus contract and reduce the risk of hemorrhage.
• Fundus rotated to the right: A fundus that is rotated to the right, along with being boggy, suggests the possibility of a full bladder or retained products of conception, both of which can prevent proper uterine contraction and contribute to hemorrhage.

Rationale for Incorrect Choices:

• Respirations 16 breaths/minute: A respiratory rate of 16 breaths/minute is normal (12-20 breaths/min) and not indicative of respiratory distress, so this finding does not require immediate follow-up.
• Episiotomy intact with no redness: The episiotomy site appears intact, with no redness or signs of infection. This is a positive finding and does not require immediate follow-up.
• 18 gauge IV to left forearm: An 18-gauge IV is appropriate for fluid administration, and there are no issues with the IV site. This does not need further attention at this time.
• Heart rate 96 beats/minute: A heart rate of 96 beats/minute is slightly elevated but not concerning by itself. It can be considered within normal postpartum variation and does not require immediate follow-up.
• IV infusing at 125 mL/hr: The IV rate of 125 mL/hr is appropriate for hydration. There are no concerns related to fluid intake or infusion rate, so no immediate action is needed.
• Voided 200 mL of clear yellow urine: The client has normal urine output (200 mL of clear yellow urine), indicating good kidney function and fluid balance. There are no concerns with the urinary system.

Rationale:

• Fundus massaged until firm and at umbilicus: Massaging the fundus until it is firm at the umbilicus indicates that uterine tone is restored, reducing the risk of postpartum hemorrhage. This is a positive sign that the uterus is contracting effectively and bleeding is controlled.
• Multiple large clots were expelled: The expulsion of multiple large clots suggests the possibility of retained blood or tissue in the uterus, which could interfere with uterine contraction and lead to continued bleeding. This increases the risk of hypovolemia.
• Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air: These vital signs suggest the patient is stable, with normal blood pressure, heart rate, and oxygen saturation, indicating good circulation and oxygenation. This reflects improvement in her overall condition, decreasing the likelihood of hypovolemia.
• Fundus remains firm with slight lochia noted on pad: A firm fundus is a good sign that uterine contractions are adequate. Slight lochia is expected in the early postpartum period, and the absence of heavy bleeding suggests improved uterine tone and no active hemorrhage.
• Straight catheter produced 500 mL clear yellow urine: A 500 mL urine output indicates that the bladder is functioning well, which may also help the uterus to contract more effectively. Proper bladder function reduces the risk of uterine displacement.

• Total blood loss of 800 mL: Blood loss of 800 mL is above the typical range for a vaginal delivery (300-500 mL), which places the patient at increased risk for hypovolemia. This amount of blood loss requires close monitoring and intervention.
• 200 mL blood loss: Although 200 mL is not extreme, ongoing blood loss that exceeds the expected range for the first few hours postpartum can still place the patient at risk for hypovolemia.