Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
3. A client, who is a 24-year-old gravida 6, para 5, delivered a 10-pound, 10-ounce baby 6 hours ago, after a 26-hour labor. Upon assessment, an RN finds the client's fundus is 2 fingerbreadths above the umbilicus and slightly deviated to the right. Based on the information provided, for which complication is this client at risk?
Test-Taking Tip
Eliminate complications that are common to all women who are pregnant, but not directly related to this client's specific risk factors.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because this client's fundus is higher than expected for this stage after delivery and is deviated to the right, indicating she has a full bladder that can impede the uterus from contracting adequately. This can result in a postpartum hemorrhage. Answer 2 is incorrect because this client is not a high risk for mastitis based on the information provided. Mastitis is a breast infection that can result from cracked or sore nipples or failure to fully drain the breast. Answer 3 is incorrect because endometriosis is a proliferation of endometrial tissue, not related to the delivery of an infant. Answer 4 is incorrect because thrombophlebitis is a risk factor for all women who are pregnant; this client is not at any increased risk because of her history with this delivery.
