Question

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Answer 1

Correct Answers:

Chills shortly following delivery

Rationale :

⏺️ Chills shortly after delivery are a significant clinical sign that may indicate infection or sepsis in the postpartum period.

⏺️ This symptom requires immediate attention because infections such as endometritis or urinary tract infections can rapidly progress and impact both maternal and newborn health.

⏺️ Early recognition of chills enables timely interventions, including diagnostic evaluation and initiation of antibiotic therapy to prevent complications.

⏺️ The nurse’s role includes vigilant monitoring for additional signs of infection, such as fever, uterine tenderness, and abnormal lochia.

⏺️ Prompt reporting and management of chills are critical steps in reducing postpartum morbidity and ensuring patient safety.

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Answer 2

Correct Answers:

Prepare a warm sitz bath.

Rationale :

🎯 A warm sitz bath is effective in relieving episiotomy pain by promoting increased blood flow, which helps reduce swelling and supports tissue healing.

🎯 Warm water soothes perineal discomfort, relaxes muscles, and can improve comfort and mobility during the postpartum period.

🎯 While ice packs are beneficial immediately after delivery (first 24 hours) to reduce swelling, after 8 hours, warmth is often more effective for pain relief.

🎯 A soft pillow may provide comfort but does not directly alleviate episiotomy pain or promote healing.

🎯 Heating lamps are generally not recommended due to the risk of burns and uneven heat application.

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Answer 3

Correct Answers:

Have the client pant during the next few contractions.

Rationale :

🟠 At 7 cm dilation and 100% effacement, the client is in the active phase of labor but not yet fully dilated (which occurs at 10 cm).

🟠 The urge to push before full dilation can cause cervical swelling and trauma, potentially prolonging labor or causing complications.

🟠 Encouraging the client to pant during contractions helps her control the urge to push, delaying pushing until full dilation is reached.

🟠 This controlled breathing technique supports safer labor progression and reduces the risk of maternal fatigue and fetal distress.

🟠 Assessing for crowning or helping to empty the bladder are appropriate later in labor, but immediate focus should be on managing premature pushing.

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Answer 4

Correct Answers:

Check the consistency of the client's uterine fundus.

Rationale :

🟠 A saturated perineal pad within 30 minutes indicates heavy postpartum bleeding, which requires immediate assessment.

🟠 The uterine fundus consistency is the first priority to determine if the uterus is firm or boggy.

🟠 A boggy uterus suggests uterine atony, the most common cause of postpartum hemorrhage, and needs prompt intervention to stimulate uterine contractions.

🟠 Assessing the fundus guides subsequent interventions such as fundal massage, oxytocic medication, or other measures.

🟠 Increasing fluid intake or having the client urinate are important but secondary actions after assessing the uterus.

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Answer 5

Correct Answers:

Lack of appetite

Rationale :

♦️ The dependent, taking-in phase typically occurs within the first 24 to 48 hours postpartum.

♦️ During this phase, the mother is often focused on her own needs, resting, and processing the birth experience.

♦️ It is common for the mother to experience a lack of appetite as her attention is inward, and she may be physically and emotionally exhausted.

♦️ Expressions of excitement and eagerness to learn newborn care are more characteristic of the taking-hold phase, which follows the dependent phase.

♦️ Focus on the family unit and its members is typical of the letting-go phase, occurring later in postpartum adjustment.

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Answer 6

Correct Answers:

Auscultate the client's abdomen.

Rationale :

🟡 After a cesarean birth, assessing bowel sounds is essential before offering any oral intake to ensure the gastrointestinal tract is functioning properly.

🟡 Auscultation helps detect return of bowel motility, which may be delayed due to anesthesia or surgical manipulation.

🟡 Offering clear liquids or soda crackers without confirming bowel function could increase the risk of nausea, vomiting, or aspiration.

🟡 Checking the diet prescription is important but secondary to assessing bowel sounds to guide safe feeding decisions.

🟡 Ensuring bowel function supports safe progression of diet and prevents postoperative complications.

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Answer 7

Correct Answers:

Fundus three fingerbreadths above the umbilicus

Rationale :

🟢 A fundus located three fingerbreadths above the umbilicus indicates that the uterus is distended, usually due to a full bladder.

🟢 A full bladder prevents the uterus from contracting properly and causes the fundus to be displaced upward and to the side.

🟢 Uterine displacement increases the risk of postpartum hemorrhage because the uterus cannot contract firmly to compress blood vessels.

🟢 Prompt urination helps the uterus contract effectively, reducing bleeding and promoting uterine involution.

🟢 Assessing fundal height and position is a key nursing skill in detecting bladder distention and preventing complications.

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Answer 8

Correct Answers:

Uterine atony

Rationale :

🟢 Uterine atony is the inability of the uterus to contract effectively after delivery.

🟢 A large baby (macrosomia, >4,000 g) increases the risk of uterine overdistension, leading to atony.

🟢 Uterine atony is the most common cause of postpartum hemorrhage, a serious complication.

🟢 Failure of the uterus to contract compresses blood vessels, resulting in excessive bleeding.

🟢 Prompt identification and management of uterine atony are critical to prevent maternal morbidity.

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Answer 9

Correct Answers:

Place the client in a lateral position.

Rationale :

🔷 Epidural anesthesia can cause sympathetic blockade, leading to vasodilation and hypotension.

🔷 Placing the client in a lateral position relieves pressure on the inferior vena cava, improving venous return and blood pressure.

🔷 Improved maternal blood flow enhances uteroplacental perfusion, benefiting fetal oxygenation.

🔷 This is the first and immediate intervention before notifying the provider or other actions.

🔷 Timely repositioning helps prevent worsening hypotension and fetal distress.

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Answer 10

Correct Answers:

Place the client in a knee-chest or Trendelenburg position

Rationale :

♦️ Umbilical cord prolapse is an obstetric emergency where the cord slips ahead of the presenting part.

♦️ The knee-chest or Trendelenburg position reduces pressure on the prolapsed cord, maintaining blood flow and oxygen to the fetus.

♦️ This position helps relieve cord compression until delivery can be expedited.

♦️ Immediate interventions to protect the fetus take precedence over explaining the situation or preparing for cesarean.

♦️Covering the cord with sterile moist saline dressing is important but secondary to positioning.

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QLexNursing

1 :
A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

2 :
A nurse is caring for a client who has unrelieved episiotomy pain 8hr following delivery. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client 2hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

5 :
A nurse is caring for a client who is 12hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

6 :
A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

7 :
A nurse is assessing a client who is 8hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

8 :
A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

9 :
A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

10 :
A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

QLexNursing

1 : A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

2 : A nurse is caring for a client who has unrelieved episiotomy pain 8hr following delivery. Which of the following actions should the nurse take?

4 : A nurse is caring for a client 2hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

5 : A nurse is caring for a client who is 12hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

6 : A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

7 : A nurse is assessing a client who is 8hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

8 : A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

9 : A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

10 : A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

1 :
A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

2 :
A nurse is caring for a client who has unrelieved episiotomy pain 8hr following delivery. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client 2hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

5 :
A nurse is caring for a client who is 12hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

6 :
A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

7 :
A nurse is assessing a client who is 8hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

8 :
A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

9 :
A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

10 :
A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?