Page 807 - Saunders Comprehensive Review For NCLEX-RN

respiratory function will assist in eliminating option 4. From the remaining options,
noting the words bleeding is excessive will assist in directing you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Maternity: Hematoma and Hemorrhage
Priority Concepts: Clinical Judgment; Clotting
Reference: McKinney et al. (2018), pp. 604-605.

264. Answer: 3

Rationale: The causes of postpartum hemorrhage include uterine atony; laceration
of the vagina; hematoma development in the cervix, perineum, or labia; and retained
placental fragments. Predisposing factors for hemorrhage include a previous history
of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of
the uterus from polyhydramnios, multiple gestation, a large neonate, infection,
multiparity, dystocia or labor that is prolonged, operative delivery such as a
cesarean or forceps delivery, and intrauterine manipulation. The multiparous client
who delivered a large fetus after oxytocin induction has more risk factors associated
with postpartum hemorrhage than do other clients. In addition, there are no specific
data in the client descriptions in options 1, 2, and 4 that present the risk for
hemorrhage.
Test-Taking Strategy: Note the strategic word, most. Focus on the subject, the
client at most risk for hemorrhage. Read the client description in each option. Noting
the words large and oxytocin in the correct option will direct you to this option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Postpartum
Health Problem: Maternity: Hematoma and Hemorrhage
Priority Concepts: Clinical Judgment; Clotting
Reference: Lowdermilk et al. (2016), pp. 486, 810.

265. Answer: 2

Rationale: Cystitis is an infection of the bladder. The client should consume 3000
mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate
interventions for perineal discomfort. Hemoglobin and hematocrit levels would be
monitored with hemorrhage.
Test-Taking Strategy: Focus on the subject, measures to treat cystitis, and note the
strategic word, priority. Remember that increased fluids are a priority intervention.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Postpartum
Health Problem: Maternity: Infection/Inflammation

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