Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?
A. Thromboembolism
This is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.
B. Cervical laceration
This is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.
C. Hemorrhoids
This is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.
D. Hemorrhage
This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
Hemorrhage. This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.
Choice A is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.
Choice B is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.
Choice C is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.
Similar Questions
A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?
A. Fundus soft, 2 fingerbreadths below the umbilicus
This is wrong because a soft fundus indicates uterine atony, which is a risk factor for hemorrhage.
B. Fundus firm, at the level of the umbilicus
choice B. Fundus firm, at the level of the umbilicus. This is because the normal postpartum uterine fundus location should be around the belly button (umbilicus) one hour after delivery and then decrease by 1 cm per 24 hours. A firm fundus indicates that the uterus is contracting well and preventing bleeding.
C. Fundus firm, 2 fingerbreadths above the umbilicus
This is wrong because the fundus should not be above the umbilicus 12 hours after delivery.
D. Fundus soft, to the right of the umbilicus
This is wrong because a fundus to the right of the umbilicus indicates a full bladder, which can displace the uterus and cause bleeding.
Full Explanation
Fundus firm, at the level of the umbilicus. This is because the normal postpartum uterine fundus location should be around the belly button (umbilicus) one hour after delivery and then decrease by 1 cm per 24 hours. A firm fundus indicates that the uterus is contracting well and preventing bleeding.
Choice A is wrong because a soft fundus indicates uterine atony, which is a risk factor for hemorrhage.
Choice C is wrong because the fundus should not be above the umbilicus 12 hours after delivery.
Choice D is wrong because a fundus to the right of the umbilicus indicates a full bladder, which can displace the uterus and cause bleeding.
During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve:
A. Gentle massage of the affected leg
This is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.
B. Anticoagulants for 6 weeks
This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.
C. Passive leg exercises twice a day
This is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.
D. Application of ice to the affected leg
This is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.
Full Explanation
Anticoagulants for 6 weeks. This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.
Choice A is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.
Choice C is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.
Choice D is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.
The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:
A. Document expected postpartum mucous membrane congestion
This is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.
B. Notify the charge nurse of a possible upper respiratory infection
This is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.
C. Notify the physician of a possible pulmonary embolism
This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.
D. Medicate with antipyretic remedy for elevated temperature
This is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.
Full Explanation
Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.
Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.
Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.
Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.