Question

A nurse is caring for a postpartum client.

Answer 1

Correct Highlights :

Perform fundal massage.
Administer blood.
Administer O2 at 2 L via nasal cannula.

Rationale :

Perform fundal massage.

🌸 The client has a boggy fundus, which indicates uterine atony, the most common cause of postpartum hemorrhage.

🌸 Fundal massage stimulates the uterus to contract and compress uterine blood vessels.

🌸 The client’s lochia increased from saturating one pad every 2 hr to soaking one pad in 1 hr, showing worsening bleeding.

🌸 A large newborn and high parity increase the risk for uterine atony due to uterine overdistention and reduced uterine tone.

🌸 Fundal massage is the immediate nursing action to control bleeding and prevent further blood loss.

Administer blood.

❤️ The client’s hemoglobin dropped from 12 g/dL to 9 g/dL, showing significant blood loss.

❤️ The hematocrit also decreased from 38.5% to 31.2%, supporting ongoing hemorrhage.

❤️ The client’s blood pressure decreased and heart rate increased, which can indicate early circulatory compensation.

❤️ Blood administration helps restore oxygen-carrying capacity and circulating volume.

❤️ This intervention is appropriate when postpartum hemorrhage causes clinically significant blood loss.

Administer O₂ at 2 L via nasal cannula.

🫁 The client’s oxygen saturation decreased from 98% to 93% on room air.

🫁 Blood loss reduces oxygen delivery to tissues because fewer red blood cells are available to carry oxygen.

🫁 Supplemental oxygen helps improve tissue oxygenation during active postpartum hemorrhage.

🫁 A nasal cannula at 2 L/min is appropriate for mild oxygen desaturation.

🫁 Oxygen support is important while the nurse also manages uterine atony and circulatory volume loss.

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Answer 2

Correct Answers:

"The most accurate indication of organ perfusion is a client's urine output."

Rationale :

🩸 Urine output is one of the most accurate clinical indicators of kidney perfusion and overall circulating volume status.

🩸 In hemorrhagic shock, blood loss reduces circulating volume, which decreases blood flow to vital organs.

🩸 A urine output of at least 30 mL/hr generally indicates adequate renal perfusion in an adult.

🩸 Decreased urine output can be an early sign that the body is shunting blood away from the kidneys to preserve perfusion to the heart and brain.

🩸 For postpartum hemorrhagic shock, close monitoring of urine output helps evaluate the severity of shock and response to fluid or blood replacement.

“Manifestations of shock might not appear until a client loses 20% of their blood volume.”

🩸Signs of shock can begin earlier or later depending on the client’s baseline condition and compensatory ability.

🩸In postpartum clients, visible blood loss can be underestimated, so nurses should not wait for a specific percentage before acting.

“Hemorrhagic shock will cause an increase in a client's serum pH level.”

🩸Hemorrhagic shock causes poor tissue perfusion and anaerobic metabolism.

🩸This leads to metabolic acidosis, which decreases serum pH.

“An infusion of 1 mL of lactated Ringer's is given for each 1 mL of blood loss.”

🩸Crystalloid replacement is often given in a larger ratio than blood loss because it does not remain fully in the intravascular space.

🩸A 1:1 lactated Ringer’s replacement does not adequately restore circulating volume in hemorrhagic shock.

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Answer 3

Correct Answers

Blank 1 Correct Option: fundal tone
Blank 2 Correct Option: heart rate

Rationale :

🌸 The client has a boggy fundus that does not firm with massage, which is a major warning sign of uterine atony and postpartum hemorrhage.

🌸 Fundal tone is the priority because a firm uterus compresses uterine blood vessels and helps control postpartum bleeding.

🌸 The client also has heavy lochia with 6 to 8 large clots, showing worsening blood loss.

🌸 After assessing the uterus, the nurse should monitor the heart rate because tachycardia is an early sign of hypovolemia and shock.

🌸 The client’s heart rate increased to 100/min with a blood pressure drop to 90/68 mm Hg, indicating possible hemorrhagic instability.

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Answer 4

Correct Answers

Blank 1 Correct Option: Postpartum hemorrhage
Blank 2 Correct Option: urinary tract Infection

Rationale :

🌺 The client is at risk for postpartum hemorrhage because the fundus is boggy, above the umbilicus, and deviated to the right, which indicates bladder distention interfering with uterine contraction.

🌺 A distended bladder prevents the uterus from contracting firmly, increasing the risk for uterine atony and excessive postpartum bleeding.

🌺 The saturated perineal pad, tachycardia of 110/min, low blood pressure, and decreased hemoglobin and hematocrit support concern for blood loss.

🌺 The client is also at risk for urinary tract infection because they had urinary retention, required straight catheterization, and had pink-tinged urine after catheter insertion.

🌺 Catheterization and incomplete bladder emptying increase the chance of bacterial entry and urinary stasis, both of which raise infection risk.

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Answer 5

Correct Answers:

Obtain prescription for a broad-spectrum antibiotic.

Rationale :

🌡️ The client has findings consistent with postpartum endometritis, including fever, chills, abdominal tenderness, and foul-smelling lochia.

🌡️ Risk factors include prolonged rupture of membranes and internal fetal monitoring, both of which increase the chance of bacteria entering the uterus.

🌡️ A temperature of 38.9°C (102°F) with tachycardia and increased respirations suggests an active infectious process.

🌡️ Broad-spectrum antibiotics are needed because postpartum uterine infections are commonly polymicrobial.

🌡️ Prompt antibiotic therapy helps prevent worsening infection, sepsis, delayed recovery, and further postpartum complications.

Instruct the client to stop breastfeeding.

🌡️Breastfeeding usually does not need to stop with postpartum endometritis.

🌡️The provider can prescribe antibiotics that are compatible with breastfeeding when possible.

Initiate airborne isolation precautions.

🌡️Airborne precautions are used for infections such as tuberculosis, measles, and varicella.

🌡️Endometritis is not spread through airborne transmission.

Place the client on strict bedrest.

🌡️Strict bedrest is not the priority treatment for postpartum uterine infection.

🌡️The client needs infection management, hydration, monitoring, and prescribed antibiotics.

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Answer 6

Correct Answers:

Heart rate 132/min

Rationale :

❤️ Terbutaline is a beta₂-adrenergic medication used to relax uterine smooth muscle and reduce preterm contractions.

❤️ A maternal heart rate of 132/min is a priority adverse effect because terbutaline can cause significant tachycardia.

❤️ Excessive tachycardia increases the risk for chest pain, dysrhythmias, hypotension, and cardiac stress.

❤️ The nurse should report this finding promptly because terbutaline is commonly held or questioned when the maternal pulse is markedly elevated.

❤️ Maternal cardiovascular status is the priority because severe tachycardia can compromise both maternal and fetal oxygenation.

Report of headache

❤️Headache can occur with terbutaline due to beta-adrenergic stimulation.

❤️It should be assessed, but it is not the priority over a heart rate of 132/min.

Nasal congestion

❤️Nasal congestion can occur with some adrenergic effects but is not usually dangerous.

❤️It does not indicate immediate cardiovascular compromise.

Tremors

❤️Tremors are a common expected adverse effect of terbutaline.

❤️They are usually less urgent than severe maternal tachycardia.

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Answer 7

Correct Answers

Digital cervical exam to assess dilation and effacement [ contraindicated ]
Administration of betamethasone [ anticipated ]
Placement of an internal fetal spiral electrode [ contraindicated ]
Administration of IV fluids [ anticipated ]
Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies [ anticipated ]
Abdominal ultrasound [ anticipated ]
Continuous monitoring of FHR [ anticipated ]

Rationale :

Anticipated

Administration of betamethasone

🌸 The client is 30 weeks gestation, so fetal lung maturity is still developing.

🌸 Betamethasone is anticipated because antepartum bleeding can increase the risk for preterm birth.

🌸 Corticosteroids help accelerate fetal lung maturity and reduce complications such as respiratory distress syndrome.

🌸 This medication is commonly given between 24 and 34 weeks gestation when preterm delivery is possible.

🌸 Because the client has ongoing bright red bleeding, preparation for possible early delivery is appropriate.

Administration of IV fluids

🌸IV fluids are anticipated because the client has ongoing vaginal bleeding.

🌸Fluid therapy helps maintain maternal circulating volume and supports uteroplacental perfusion.

🌸Even though current vital signs are stable, bleeding can worsen quickly in placenta previa or other antepartum bleeding conditions.

🌸IV access also allows rapid medication or blood product administration if the client becomes unstable.

🌸Maintaining maternal perfusion is essential because fetal oxygenation depends on maternal circulation.

Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies

🌸Laboratory testing is anticipated because the client has moderate bright red bleeding at 30 weeks gestation.

🌸A CBC helps evaluate hemoglobin, hematocrit, and platelet status.

🌸Blood type and Rh testing are important in case blood products or Rh immune globulin are needed.

🌸Coagulation studies help assess bleeding risk and detect clotting complications.

🌸These labs provide baseline data and guide urgent treatment if bleeding increases.

Abdominal ultrasound

🌸Abdominal ultrasound is anticipated because the client has painless, bright red bleeding, which is suspicious for placenta previa.

🌸Ultrasound helps locate the placenta and determine whether it is near or covering the cervical opening.

🌸This client has not had an ultrasound during pregnancy, making placental location unknown.

🌸Ultrasound is a safe, noninvasive way to evaluate the cause of bleeding before any cervical examination.

🌸Confirming placenta location is essential because cervical manipulation can cause severe hemorrhage if previa is present.

Continuous monitoring of FHR

🌸Continuous fetal heart rate monitoring is anticipated because maternal bleeding can reduce uteroplacental perfusion.

🌸FHR assessment helps identify fetal distress early if bleeding worsens.

🌸The current FHR of 148/min with moderate variability is reassuring, but ongoing bleeding requires continued monitoring.

🌸Continuous monitoring also helps evaluate contraction activity and fetal response.

🌸This intervention supports early recognition of maternal or fetal compromise.

Contraindicated

Digital cervical exam to assess dilation and effacement

🌸A digital cervical exam is contraindicated until placenta previa is ruled out by ultrasound.

🌸If the placenta is covering or near the cervix, a digital exam can trigger massive hemorrhage.

Placement of an internal fetal spiral electrode

🌸Internal fetal spiral electrode placement is contraindicated with unexplained vaginal bleeding and suspected placenta previa.

🌸It requires cervical access and can increase bleeding or introduce infection risk.

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Answer 8

Correct Answers:

Epigastric pain

Rationale :

⚠️ Epigastric pain at 33 weeks of gestation can indicate preeclampsia with severe features.

⚠️ This pain can occur from liver involvement, hepatic swelling, or decreased perfusion related to worsening hypertensive disease.

⚠️ It is a serious warning sign because preeclampsia can progress to seizures, stroke, HELLP syndrome, placental abruption, or fetal compromise.

⚠️ The nurse should report this finding promptly so the provider can assess blood pressure, urine protein, platelets, liver enzymes, and fetal status.

⚠️ Epigastric or right upper quadrant pain is not considered a normal discomfort of pregnancy and needs urgent follow-up.

Leukorrhea

⚠️Leukorrhea is a common pregnancy finding caused by increased estrogen and vaginal blood flow.

⚠️It is usually expected if it is thin, white, mild-smelling, and not associated with itching or irritation.

Excessive salivation

⚠️Excessive salivation, or ptyalism, can occur during pregnancy and is usually not dangerous.

⚠️It may be uncomfortable, but it is not the priority finding to report.

Darkening of the skin on the face

⚠️Darkening of facial skin is called chloasma or the “mask of pregnancy.”

⚠️It is a common hormonal skin change and does not require urgent provider notification.

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Answer 9

Correct Answers:

A client who has an indwelling urinary catheter

Rationale :

🟦 A postpartum client with an indwelling urinary catheter is at increased risk for a fall because tubing and the drainage bag can interfere with safe ambulation.

🟦 The catheter can become tangled, pulled, or caught during movement, increasing the chance of tripping.

🟦 Postpartum clients may also have weakness, fatigue, blood loss, or residual effects from anesthesia, which can further increase fall risk.

🟦 The nurse should assist with ambulation and ensure the drainage bag remains below bladder level without dragging on the floor.

🟦 Fall prevention includes keeping the call light within reach, clearing the pathway, and instructing the client to ask for help before getting up.

A client who has a second-degree perineal laceration

🟦A second-degree perineal laceration can cause pain and discomfort during movement.

🟦However, by itself it is not the strongest fall-risk factor compared with catheter tubing and mobility hazards.

A client who is saturating a perineal pad every 5 to 6 hr

🟦Saturating a pad every 5 to 6 hr is not excessive postpartum bleeding.

🟦Heavy bleeding is usually more concerning when a pad is saturated in 1 hour or less.

A client who is experiencing breast engorgement

🟦Breast engorgement causes breast fullness, tenderness, and discomfort.

🟦It does not directly increase the risk for falls.

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Answer 10

Correct Answers:

Heart rate 54/min

Rationale :

❤️ Labetalol is a beta blocker used to lower blood pressure in clients with preeclampsia.

❤️ A heart rate of 54/min indicates bradycardia, which is a reason to withhold labetalol and notify the provider.

❤️ Labetalol can further decrease the heart rate by blocking beta-adrenergic stimulation of the heart.

❤️ Giving the medication when the pulse is already low can increase the risk for symptomatic bradycardia, dizziness, hypotension, and poor perfusion.

❤️ The nurse should reassess vital signs and follow provider or facility parameters before administering the medication.

Uric acid 7.5 mg/dL

❤️ An elevated uric acid level can occur with preeclampsia due to decreased renal clearance.

❤️ It should be monitored, but it is not a direct reason to withhold labetalol.

FHR 112/min

❤️ A fetal heart rate of 112/min is within the lower end of the expected range of 110 to 160/min.

❤️ This finding does not require withholding labetalol.

BUN 23 mg/dL

❤️ A BUN of 23 mg/dL is mildly elevated and can reflect decreased renal perfusion in preeclampsia.

❤️ It should be monitored, but the immediate medication concern is the client’s bradycardia.

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QLexNursing

1 :
A nurse is caring for a postpartum client.

Correct Highlights :

2 :
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

3 :
A nurse is caring for a client who is in the fourth stage of labor.

Correct Answers

4 :
A nurse is caring for a client following an emergency cesarean birth.

Correct Answers

5 :
Patient Data.

Answer Options

6 :
A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

7 :
A nurse on an antepartum unit is caring for a client.

Correct Answers

8 :
A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

9 :
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

10 :
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?

QLexNursing

1 : A nurse is caring for a postpartum client.

Correct Highlights :

2 : A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

3 : A nurse is caring for a client who is in the fourth stage of labor.

Correct Answers

4 : A nurse is caring for a client following an emergency cesarean birth.

Correct Answers

5 : Patient Data.

Answer Options

6 : A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

7 : A nurse on an antepartum unit is caring for a client.

Correct Answers

8 : A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

9 : A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

10 : A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?

1 :
A nurse is caring for a postpartum client.

2 :
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?

3 :
A nurse is caring for a client who is in the fourth stage of labor.

4 :
A nurse is caring for a client following an emergency cesarean birth.

5 :
Patient Data.

6 :
A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

7 :
A nurse on an antepartum unit is caring for a client.

8 :
A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

9 :
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

10 :
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?