A nurse is caring for a client who is 5 hours postpartum following a successful vaginal birth of twins. The nurse should recognize that this client is at increased risk for which of the following postpartum complications?
Mastitis.
Uterine infection.
Uterine atony.
Retained placental fragments.
The Correct Answer is C
Choice A rationale
Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It is more common in breastfeeding women and typically occurs when bacteria enter the breast tissue through a cracked or sore nipple. While it is a postpartum complication, it is not specifically associated with the delivery of twins.
Choice B rationale
Uterine infection, also known as endometritis, is an infection of the uterine lining. It can occur after childbirth, especially if there were complications such as prolonged labor, multiple vaginal exams, or manual removal of the placenta. However, it is not specifically associated with the delivery of twins.
Choice C rationale
Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. The risk of uterine atony is higher in cases of overdistension of the uterus, such as with multiple gestations (twins), polyhydramnios, or a large baby. Therefore, a client who has delivered twins is at increased risk for uterine atony.
Choice D rationale
Retained placental fragments occur when parts of the placenta remain in the uterus after childbirth. This can lead to postpartum hemorrhage and infection. While it is a potential complication, it is not specifically associated with the delivery of twins.
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Correct Answer is D
Explanation
Choice A rationale
Changing the dressing on a cesarean incision for a patient who is 1 day post-op requires sterile technique and assessment skills, which are beyond the scope of practice for assistive personnel (AP). This task should be performed by a licensed nurse.
Choice B rationale
Documenting the lochia amount on the perineal pad of a client who just transferred from labor and delivery involves assessment and documentation, which are nursing responsibilities. This task should not be delegated to AP.
Choice C rationale
Assessing an area of redness on the breast of a client who is 4 days postpartum requires clinical judgment and assessment skills, which are within the scope of practice for a licensed nurse. This task should not be delegated to AP.
Choice D rationale
Providing a sitz bath to a client who has a third-degree laceration and is 2 days postpartum is an appropriate task for AP. It is a comfort measure that does not require clinical judgment or assessment skills, making it suitable for delegation to AP.
Correct Answer is C
Explanation
Choice A rationale
Asking the client to rate her pain is important for assessing discomfort, but it does not address the immediate issue of a deviated fundus. A deviated fundus often indicates a full bladder, which can impede uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
Encouraging the client to perform Kegel exercises is beneficial for pelvic floor strengthening but does not address the immediate concern of a deviated fundus. The priority is to ensure the uterus can contract properly.
Choice C rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus, preventing it from contracting effectively and increasing the risk of hemorrhage. Voiding helps the uterus return to its proper position and function.
Choice D rationale
Encouraging the client to move to the left lateral position may provide comfort but does not address the underlying issue of a full bladder causing uterine displacement.