OB McKinney Ch 28: The Woman with a Postpartum Complication

1. Which statement by a postpartum woman indicates that teaching about thrombus formation has been effective? a. "I'll stay in bed for the first 3 days after my baby is born." b. "I'll keep my legs elevated with pillows." c. "I'll sit in my rocking chair most of the time." d. "I'll put my support stockings on every morning before rising." ANS: D Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning. As soon as possible, the woman should ambulate frequently. The mother should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities. 2. The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a. uterine atony. b. uterine inversion. c. vaginal hematoma. d. vaginal laceration. ANS: A Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. The other situations can cause bleeding but are not the most common cause. 00:33 01:36 3. The nurse knows that a measure for preventing late postpartum hemorrhage is to a. administer broad-spectrum antibiotics. b. inspect the placenta after delivery. c. manually remove the placenta. d. pull on the umbilical cord to hasten the delivery of the placenta. ANS: B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. Manual removal of the placenta increases the risk of postpartum hemorrhage. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion. 4. A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. What action should the nurse take next? a. Continue to massage the fundus. b. Notify the provider. c. Recheck vital signs. d. Insert an indwelling urinary catheter. ANS: B After taking these corrective actions, the nurse should contact the provider and anticipate collaborative care measures. Another nurse can assess vital signs. Since the woman just voided, an indwelling catheter is not needed. 5. Early postpartum hemorrhage is defined as signs and symptoms of hypovolemia with which of the following descriptions of blood loss? a. Cumulative blood loss 1000 mL in the first 24 hours after the birth process. b. 750 mL in the first 24 hours after vaginal delivery c. Cumulative blood loss 1000 mL in the first 48 hours after the birth process d. 1500 mL in the first 48 hours after cesarean delivery ANS: A The newest definition of early postpoartum hemorrhage is cumulative blood loss 1000 mL with signs of hypovolemia within the first 24 hours after the birth process. Hemorrhage after 24 hours is considered late postpartum hemorrhage. 6. A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations. ANS: B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Calling for help is not needed unless corrective action does not improve the situation. Another nurse can take the blood pressure or the original nurse can do so after assessing the fundus and massaging it if needed. Checking the perineum for lacerations would be appropriate if the fundus was firm. 7. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a. uterine atony. b. lacerations of the genital tract. c. perineal hematoma. d. infection of the uterus. ANS: B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise. 8. A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n) a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor. ANS: B A rapid (precipitous) labor and delivery may cause exhaustion of the uterine muscle and prevent contraction. The use of forceps may cause lacerations that could lead to bleeding, but that is not as common as hemorrhage after a precipitous labor when they are used only in the outlet. Eight-hour and 12-hour labors are normal in length. 9. What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected. ANS: B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. Large clots after discharge are a sign of complications and should be reported. 10. Which woman is at greatest risk for early postpartum hemorrhage? a. A primiparous woman being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced c. A multiparous woman with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins ANS: B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. The other situations do not post risk factors or causes of early PPH. 11. When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is a. absence of cyanosis in the buccal mucosa. b. cool, dry skin. c. diminished restlessness. d. decreased urinary output. ANS: D Hemorrhage may result in hypovolemic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective in nature. The presence of cool, pale, clammy skin is an indicative finding associated with hypovolemic shock. Restlessness indicates decreased cerebral perfusion. 12. The nurse should expect medical intervention for subinvolution to include a. oral methylergonovine maleate (Methergine) for 48 hours. b. oxytocin intravenous infusion for 8 hours. c. oral fluids to 3000 mL/day. d. intravenous fluid and blood replacement. ANS: A Methergine provides long-sustained contraction of the uterus and is the usual treatment. Oxytocin and oral fluids are not used for this condition. There is no indication that blood loss has occurred in this situation; if it does blood replacement may be necessary.