What is the primary risk associated with a retained placenta?

Correct Answer: B

Rationale: The primary risk associated with a retained placenta is postpartum hemorrhage. When the placenta is not properly expelled after childbirth, it can lead to excessive bleeding. This is because the uterus may not contract effectively to close off blood vessels once the placenta is removed. Postpartum hemorrhage can be life-threatening if not promptly managed. Option A: Neonatal jaundice is not directly related to a retained placenta. Neonatal jaundice occurs when a baby's liver is not fully developed, leading to a buildup of bilirubin in the blood. This is a separate issue from placental retention. Option C: Delayed bonding is not a primary risk associated with a retained placenta. While it can impact the emotional connection between the mother and baby, it is not a life-threatening complication like postpartum hemorrhage. Option D: Postpartum anemia can occur as a result of excessive bleeding from a retained placenta, but it is not the primary risk. Postpartum anemia is a condition where there is a low red blood cell count after childbirth, leading to fatigue and weakness. It is a consequence of postpartum hemorrhage rather than the main risk associated with a retained placenta.

Correct Answer: C

Rationale: Assessing the perineum after birth is primarily done to detect any signs of perineal trauma. This is because perineal trauma, such as tears or lacerations, is a common occurrence during childbirth and can lead to complications if not identified and treated promptly. By assessing the perineum, healthcare providers can determine the extent of any trauma and provide appropriate interventions to promote healing and prevent infection. Option A, to evaluate the birthing person's readiness for discharge, is incorrect because assessing the perineum is not solely about determining readiness for discharge. While the condition of the perineum may factor into discharge decisions, the primary purpose is to assess for trauma. Option B, to ensure the birthing person can ambulate safely, is also incorrect because assessing the perineum is not directly related to the birthing person's ability to walk safely. While perineal trauma may impact mobility, the main focus is on identifying and treating any trauma present. Option D, to assess the status of cervical dilation, is incorrect because cervical dilation is not related to assessing the perineum after birth. Cervical dilation is typically monitored during labor to track progress and guide interventions, but it is not relevant to assessing perineal trauma post-birth.

Correct Answer: B

Rationale: Labor dystocia refers to difficult or prolonged labor, which can increase the risk of complications for both the mother and baby. A 41-year-old woman is at high risk for labor dystocia due to advanced maternal age. As women age, their uterine muscles may not contract as effectively, leading to inefficient labor progress. This can result in prolonged labor, increased risk of instrumental deliveries (forceps or vacuum), and higher rates of cesarean sections. Choice A, 38-week gestation, is not necessarily a risk factor for labor dystocia. Full-term pregnancy is considered to be between 37-42 weeks, so a 38-week gestation is within the normal range and does not inherently increase the risk of labor dystocia. Choice C, prenatal anemia, can contribute to maternal fatigue and weakness during labor, but it is not a direct risk factor for labor dystocia. Anemia can be managed with appropriate prenatal care and iron supplementation to reduce its impact on labor. Choice D, no prenatal care, is a significant risk factor for various complications during pregnancy and labor, but it is not directly associated with labor dystocia. Lack of prenatal care can lead to undiagnosed medical conditions, inadequate monitoring of fetal well-being, and missed opportunities for interventions that could prevent labor dystocia. In conclusion, a 41-year-old woman is at high risk for labor dystocia due to advanced maternal age, while the other choices are not directly linked to this specific complication. It is important for healthcare providers to recognize these risk factors and provide appropriate management to optimize outcomes for both the mother and baby.

Correct Answer: B

Rationale: Amniotomy is a procedure where the amniotic sac is artificially ruptured to induce or accelerate labor. Choice A, a six-hour decrease of labor, is incorrect because while amniotomy can sometimes speed up labor, it is not guaranteed to reduce labor by a specific amount of time. It may vary depending on individual factors. Choice C, elevated blood pressure, is also incorrect. Amniotomy does not directly cause elevated blood pressure. Elevated blood pressure during labor can be a sign of other complications such as preeclampsia, but it is not a direct result of amniotomy. Choice D, second stage labor dystocia, is also incorrect. Amniotomy is more commonly associated with the first stage of labor rather than the second stage. Second stage labor dystocia is usually related to issues with the baby's position or maternal pushing efforts, not the rupture of the amniotic sac. The correct answer is B, chorioamnionitis. Amniotomy increases the risk of chorioamnionitis, which is an infection of the fetal membranes. This is because the protective barrier of the amniotic sac is broken, providing a pathway for bacteria to enter and infect the amniotic fluid. Chorioamnionitis can lead to serious complications for both the mother and baby, including sepsis and preterm birth. It is important for healthcare providers to closely monitor for signs of infection after an amniotomy.

Correct Answer: A

Rationale: A: Assessing deep tendon reflexes for hyperreflexia is the correct nursing intervention for preeclampsia because hyperreflexia is a common sign of worsening preeclampsia. This assessment helps in early detection of neurological complications such as eclampsia, which is a severe form of preeclampsia characterized by seizures. Prompt identification of hyperreflexia allows for timely intervention to prevent further complications. B: Providing frequent IV fluid boluses is not the appropriate intervention for preeclampsia. In fact, excessive fluid administration can exacerbate hypertension and lead to fluid overload, putting the patient at risk for pulmonary edema. Careful fluid management is crucial in managing preeclampsia, but it should be done judiciously and based on the patient's fluid status. C: Educating the laboring person that preeclampsia is only a concern for pregnancy, not labor, is incorrect. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems. It can occur before, during, or after labor, and it requires close monitoring and management throughout the perinatal period to ensure the safety of both the parent and the baby. D: Discouraging pain medication in order to assess for a headache is not a recommended nursing intervention for preeclampsia. Headaches are a common symptom of preeclampsia, and pain management should be provided to alleviate discomfort and improve the patient's overall well-being. Delaying pain relief can lead to unnecessary suffering and does not contribute to the assessment and management of preeclampsia.