Level: Advanced
Difficulty: Hard
Subtopic: Maternal emergencies
NCLEX: A postpartum client on the mother-baby unit is being evaluated for postpartum hemorrhage risk. Assessment data in…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for postpartum hemorrhage risk. Assessment data include temperature 101.4°F (38.6°C), uterine tenderness, and foul-smelling lochia. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that temperature 101.4°F (38.6°C), uterine tenderness, and foul-smelling lochia.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that temperature 101.4°F (38.6°C), uterine tenderness, and foul-smelling lochia.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that temperature 101.4°F (38.6°C), uterine tenderness, and foul-smelling lochia.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.