NCLEX-RN Practice Test 7

0930 — Spontaneous vaginal birth at 0912; placenta delivered intact at 0920. Quantitative blood loss (QBL) at birth 450 mL. Fundus firm, midline, at the umbilicus. Lochia rubra, moderate. Client shivering; warm blankets applied. Newborn skin-to-skin; breastfeeding initiated.

1000 — Fundus firm, midline, 1 cm above the umbilicus. Lochia rubra, moderate, with small clots. Epidural catheter removed at 0945; client moves both legs. Ice pack applied to perineum for comfort.

1045 — Client states, "I feel a big gush and I'm lightheaded." Fundus boggy, 2 cm above the umbilicus and deviated to the right. Lochia rubra, heavy; peripad saturated in 15 minutes with a 6-cm clot. QBL since 1000: 600 mL; cumulative QBL 1,050 mL. Bladder distended above the symphysis pubis; has not voided since birth. Skin pale, cool and clammy. Perineum intact with mild edema. Reported cramping while breastfeeding at 1015. Oxytocin infusing at 125 mL/h through an 18-gauge IV in the left forearm.

Labor and birth summary: 32-year-old, now gravida 3 para 3, at 40 weeks 3 days. Two previous vaginal births. Lost 1,100 mL of blood after her second birth 3 years ago. Labor augmented with oxytocin for 14 hours. Epidural analgesia placed at 4 cm dilation. Second stage of labor lasted 3 hours 10 minutes. Spontaneous vaginal birth at 0912 of a newborn weighing 4,350 g. Placenta delivered intact at 0920. Perineum intact; no lacerations. Blood type O positive; rubella immune. Mild persistent asthma controlled with inhaled fluticasone.

Medications before admission: prenatal vitamin daily, fluticasone 110 mcg 2 puffs inhaled twice daily, albuterol inhaler PRN (last used 2 months ago). Allergies: none known. Weight 78 kg. Antepartum course uncomplicated; blood pressure normal throughout pregnancy.

Day 2, 0930 postpartum orders: • Vital signs, fundus and lochia every 15 minutes for 1 hour, every 30 minutes for 1 hour, then every 4 hours • Oxytocin 30 units in 500 mL lactated Ringer's IV at 125 mL/h until the bag is complete • Quantify blood loss by weighing pads (1 g = 1 mL) • Straight urinary catheterization PRN for bladder distension or inability to void within 4 hours • Ibuprofen 600 mg PO every 6 hours PRN pain • Ice pack to perineum PRN • Fluticasone 110 mcg 2 puffs inhaled twice daily; albuterol 2 puffs inhaled every 4 hours PRN wheezing • First ambulation with nurse assistance • Notify provider for cumulative QBL of 1,000 mL or more, HR above 110/min, or SBP below 90 mm Hg