A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion?

Correct Answer: A

Rationale: The correct answer is A) My lower back hurts all of a sudden. The complaint of sudden lower back pain in a client receiving a blood transfusion post placenta accreta and hysterectomy would warrant immediately discontinuing the infusion as it could indicate an adverse reaction such as a transfusion reaction, which may lead to serious complications including kidney damage. Option B) My hands feel so cold is less concerning as cold hands can be a common side effect of blood transfusion and may not necessarily indicate a severe reaction. Option C) I feel like my heart is beating fast could be due to the body's response to the blood transfusion and may not always indicate a need for immediate discontinuation. Option D) I feel like I need to have a bowel movement is unrelated to a potential adverse reaction to the blood transfusion and would not warrant discontinuing the infusion. Educationally, it is crucial for healthcare providers to be able to recognize signs and symptoms of adverse reactions to blood transfusions, as prompt action is essential in ensuring patient safety and well-being. Monitoring for such reactions and knowing when to intervene is a critical aspect of postpartum care for clients who have undergone complex procedures like placenta accreta and hysterectomy.

Correct Answer: B

Rationale: In this scenario, option B, "Urinary output 240 mL/12 hr," is the correct answer as a precipitating factor for the client's findings. A decreased urinary output indicates renal impairment, which can lead to magnesium sulfate toxicity. Magnesium sulfate is used to prevent seizures in severe preeclampsia; however, in excessive amounts, it can depress the central nervous system, causing decreased reflexes and respiratory depression. Option A, "Apical heart rate 104 bpm," is incorrect as it is within the normal range and not directly related to the client's current presentation. Option C, "Blood pressure 160/120," while indicative of hypertension, is not the precipitating factor for the client's decreased reflexes and respiratory rate. Option D, "Temperature 100°F," is also not directly related to the client's symptoms. Educationally, understanding the effects and side effects of medications used in the management of preeclampsia, such as magnesium sulfate, is crucial for nurses and healthcare providers caring for postpartum clients. Monitoring urinary output, reflexes, and respiratory status is essential to prevent and detect potential complications related to medication toxicity.

Correct Answer: B

Rationale: The correct answer is B) Teach sitz bath use on the second postoperative day. Post-cesarean clients experience hormonal changes that affect their physical and emotional well-being. Teaching sitz bath use promotes perineal healing, reduces the risk of infection, and provides comfort. It also encourages self-care and empowers the client in her recovery process. Option A is incorrect as maintaining the client in a left lateral recumbent position is not typically necessary post-cesarean section. Option C is incorrect because performing active range-of-motion exercises may not be suitable immediately post-cesarean due to pain and the need for rest and healing. Option D is incorrect because assessing central venous pressure is not a standard nursing intervention for a post-cesarean client. This procedure is typically reserved for specific medical conditions and not routine postoperative care. Educationally, understanding the rationale behind each option helps nurses develop critical thinking skills in providing individualized care based on the client's needs and condition. It also emphasizes the importance of evidence-based practice in postpartum care.

Correct Answer: D

Rationale: In the postpartum period, it is essential for nurses to be vigilant for signs of puerperal infection, as prompt recognition and treatment are crucial. The correct answer is D) Malodorous lochial discharge. This symptom is indicative of a possible uterine infection, as foul-smelling lochia can be a sign of endometritis, a common puerperal infection. Option A) Temperature of 100.2°F could be seen as a normal finding in the immediate postpartum period due to physiological changes, such as milk coming in, and may not necessarily indicate infection. Option B) White blood cell count of 14,500 cells/mm3 is slightly elevated but not specific to puerperal infection, as WBC count can be elevated post-delivery. Option C) Diaphoresis during the night is a common postpartum symptom due to hormonal shifts and is not a specific indicator of puerperal infection. It is important for nurses to understand the normal postpartum changes to differentiate them from signs of infection to provide appropriate care and intervention for the mother. Educationally, nurses need to be taught to assess and differentiate between normal postpartum occurrences and signs of complications like puerperal infection. Understanding the significance of malodorous lochia as a potential indicator of infection can lead to early intervention, preventing the escalation of complications and promoting the well-being of the postpartum woman.

Correct Answer: C

Rationale: In a 3-week-multigravid postpartum client with postpartum depression, the nurse should expect to observe feelings of failure as a mother. This is the correct answer because postpartum depression often manifests as feelings of inadequacy, guilt, and worthlessness, leading the mother to believe she is not capable of being a good mother. Option A, feelings of infanticide, is incorrect as this is a severe symptom of postpartum psychosis, not postpartum depression. Option B, difficulty with breastfeeding latch, is a common challenge in the postpartum period but is not specifically associated with postpartum depression. Option D, concerns about sibling jealousy, may be a valid concern for some mothers but is not typically a significant behavior seen in postpartum depression. Educationally, understanding the behavioral manifestations of postpartum depression is crucial for healthcare providers to provide appropriate support and interventions for mothers experiencing this condition. By recognizing the signs and symptoms, healthcare professionals can offer timely and effective care to promote the well-being of both the mother and the newborn.