A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. ...

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A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline.
 
  In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:
  a. Urinary tract infection. c. A ruptured bladder.
  b. Excessive uterine bleeding. d. Bladder wall atony.

Question 2

The nurse caring for the postpartum woman understands that breast engorgement is caused by:
 
  a. Overproduction of colostrum.
  b. Accumulation of milk in the lactiferous ducts.
  c. Hyperplasia of mammary tissue.
  d. Congestion of veins and lymphatics.

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Answer to Question 1

ANS: B
Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

Answer to Question 2

ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue.