The nurse is assessing a patient who is a G5P5005 and delivered vaginally four hours ago. The patient's labor history includes a 16-hour oxytocin induction for a macrosomic infant.
Assessment findings include a firm uterus and a completely saturated peri pad with the presence of blood clots.
What does the nurse identify as the most likely cause for the increased bleeding?
Tissue.
Trauma.
Thrombin.
Tone.
The Correct Answer is B
Choice A rationale
Retained tissue can cause postpartum hemorrhage, but with a firm uterus and no other signs of retained placenta, this is less likely the cause here.
Choice B rationale
Trauma is the most likely cause of increased bleeding in this scenario. The prolonged oxytocin induction and macrosomic infant suggest a higher risk of lacerations or uterine atony
despite the firm uterus.
Choice C rationale
Thrombin disorders cause bleeding due to clotting issues. However, this patient shows signs of active bleeding and clotting, making this less likely.
Choice D rationale
Uterine atony, indicated by a soft, boggy uterus, is a common cause of postpartum hemorrhage, but in this case, the uterus is firm, so it's less likely to be the cause.
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Correct Answer is A
Explanation
Choice A rationale
Blood pressure of 160/110 indicates severe preeclampsia and warrants immediate intervention to prevent complications. Stopping oxytocin is part of the management of severe
preeclampsia to avoid exacerbating the condition.
Choice B rationale
Frequency of contractions every 3 minutes is within the normal range during labor induction and does not warrant stopping the infusion unless there are other concerns.
Choice C rationale
A fetal heart rate of 155 bpm with early decelerations may require close monitoring but does not necessarily warrant stopping the oxytocin infusion. Early decelerations are typically a
normal physiological response.
Choice D rationale
Frequency of contractions every 3 minutes is expected during active labor and is generally not a cause to stop the oxytocin infusion. The nurse should continue to monitor the labor
progression closely.
Correct Answer is D
Explanation
Choice A rationale
Reflexes of 3+ indicate hyperreflexia, common in pre-eclampsia, but not necessarily critical. Monitoring is essential but not an emergency.
Choice B rationale
Urinary output of 30 mL/hr is within the acceptable range but requires monitoring for any changes. It's not a critical alert.
Choice C rationale
A respiratory rate of 16 rpm is normal and does not indicate immediate risk requiring physician notification.
Choice D rationale
Serum magnesium level of 10 mg/dL is significantly high, indicating potential toxicity. Immediate physician notification is critical to adjust magnesium sulfate administration.