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 A
Explanation
Choice A rationale
Galactopoiesis is the process of lactation maintenance and is reliant on breast stimulation and milk removal. This stage involves the ongoing production of milk in response to the infant’s demand.
Choice B rationale
Lactogenesis II refers to the onset of copious milk secretion that occurs around 2-3 days postpartum. It is triggered by the withdrawal of progesterone following the delivery of the placenta.
Choice C rationale
Mammogenesis is the development of the mammary glands during pregnancy. It involves the growth and differentiation of the breast tissue in preparation for lactation.
Choice D rationale
Lactogenesis I refers to the initial stage of milk production that begins during pregnancy and continues through the early postpartum period. It is hormonally driven and prepares the breasts for lactation. .
Correct Answer is A
Explanation
Choice A rationale
Asking the client if she has thoughts of or considered harming herself or her newborn is the priority action. This assessment is crucial for identifying postpartum depression and potential risks to the client and her newborn. Early identification and intervention can prevent harm.
Choice B rationale
Anticipating a prescription for an antidepressant is important but secondary to assessing immediate safety concerns. Medication can be part of the treatment plan after assessing the client’s mental state.
Choice C rationale
Assisting the family to identify prior use of positive coping skills is beneficial for long-term management but is not the immediate priority. The nurse must first ensure the client’s and newborn’s safety.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important for overall care but does not address the immediate concern of potential harm due to postpartum depression.