Question

. The nurse is assessing the client two hours after delivery of a 9 lb. infant. Which problem should receive priority? ? A. Redness and edema of the perineum ? B. Extreme thirst and complaints of pain in the perineium ? C. Uterus displacement to the left side of the abdomen ? D. Breast tenderness and dripping of colostrum from the nipples

Short answer

Answer: C. Uterus displacement to the left side of the abdomen.

Step-by-step solution

Understand the four potential problems

To solve this exercise, we need to understand the implications of each potential problem mentioned. The four problems the nurse is assessing are: A. Redness and edema of the perineum. B. Extreme thirst and complaints of pain in the perineum. C. Uterus displacement to the left side of the abdomen. D. Breast tenderness and dripping of colostrum from the nipples.

Assess the risks and implications of each problem

We will now analyze each problem in order to determine the priority. A. Redness and edema of the perineum: These are normal signs that may occur after delivery due to stretching and pressure during childbirth. This is relatively common and usually resolves within a few days. B. Extreme thirst and complaints of pain in the perineum: Extreme thirst might be a sign of dehydration, which might be harmful to the mother if not managed well. Pain in the perineum adds to the discomfort and is also an indication of trauma or stress experienced during childbirth. C. Uterus displacement to the left side of the abdomen: This could suggest that there is a subinvolution of the uterus or retained products of conception, which may lead to postpartum hemorrhage or infection. It is essential to quickly assess and manage this condition to prevent complications. D. Breast tenderness and dripping of colostrum from the nipples: Breast tenderness and colostrum production are normal physiological processes following childbirth as the body prepares for breastfeeding. While it may cause discomfort, this is not a high-priority issue compared to other problems presented in this case.

Determine the priority problem

Now that we understand each problem and its implications, we can determine which one should receive priority. A. Redness and edema of the perineum: Low priority since it is a normal postpartum response B. Extreme thirst and complaints of pain in the perineum: Moderate priority, as dehydration might be harmful to the mother, and pain in the perineum adds distress C. Uterus displacement to the left side of the abdomen: High priority, due to the risk of postpartum hemorrhage or infection if not managed promptly D. Breast tenderness and dripping of colostrum from the nipples: Low priority, as it is a normal postpartum response Based on the analysis, the priority problem is: ? C. Uterus displacement to the left side of the abdomen.

Key concepts

Postpartum Complications

The period following childbirth, known as postpartum, is a critical time during which a mother's body undergoes numerous changes and begins to heal. Complications during this period can impact a mother's health and wellbeing. Among common issues are infections, high blood pressure, and mental health concerns like postpartum depression.

However, one of the most serious complications is postpartum hemorrhage, which is excessive bleeding after the birth of a baby. It's crucial for medical professionals to monitor signs that could lead to such complications. For example, uterine atony, where the uterus doesn't properly contract, can lead to significant blood loss. Retained placental fragments and perineal lacerations can also be critical factors. Therefore, a thorough assessment by the nurse, including understanding the normalcy and severity of various symptoms, is key to preventing long-term issues.

Through vigilant assessment and interventions, healthcare providers can greatly reduce the risk and impact of postpartum complications, ensuring a safer recovery for the new mother.

NCLEX-PN Maternal Care

For nursing students preparing for the NCLEX-PN exam, understanding maternal care post-delivery is crucial. This includes recognizing signs and symptoms that may indicate postpartum complications and knowing how to prioritize treatment.

The NCLEX-PN exam may pose scenarios requiring the test-taker to make judgment calls on the most severe symptoms needing immediate attention. For example, understanding that uterine displacement suggests potentially serious complications and warrants quick action, while other symptoms like breast tenderness are usually part of normal postpartum changes, is essential.

Nursing interventions during the postpartum period focus on prevention and management of hemorrhage, infections, and other potential complications as well as providing support and education to the new mother. Practical knowledge and the ability to apply critical thinking, as practiced with exercise questions similar to the given example, can prepare students for real-world maternal care challenges.

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality worldwide and a critical topic for both maternal care and the NCLEX-PN exam. PPH is typically defined as the loss of 500 milliliters or more of blood after vaginal delivery or 1,000 milliliters or more after a cesarean section. It usually occurs within 1 day of giving birth but can happen up to 12 weeks later.

Risk factors for PPH include uterine atony, trauma to the birth canal, retained placenta, and coagulopathies. The mother’s vitals, such as blood pressure and heart rate, can signal the onset of PPH, as can a displaced uterus, which might indicate internal bleeding and the presence of retained placental fragments.

Treatment should be swift and can involve uterine massage, medication to contract the uterus, and in some cases, surgery. Blood transfusions may also be necessary. Educating nurses on the protocols to address PPH is an integral part of maternal care training, preparation for the NCLEX-PN, and effective patient care.