C211 MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK

C211 MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK Chapter 21: Postpartum Complications Perry: Maternal Child Nursing Care, 6th Edition MULTIPLE CHOICE 1. 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 after birth hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient’s bleeding. Furthermore, if the woman is experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic.COM 2. A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: a. establish venous access. b. perform fundal massage. c. prepare the woman for surgical intervention. d. catheterize the bladder. ANS: B The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her after birth hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the patient to eliminate any bladder distention that may be preventing the uterus from contracting properly. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 3. The perinatal nurse caring for the after birth woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. subinvolution of the placental site. b. defective vascularity of the decidua. c. cervical lacerations. d. coagulation disorders. ANS: A Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 4. Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress. b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced. c. A multiparous woman (G 3 P 2 0 0 2) 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. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency C-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 5. The first and most important nursing intervention when a nurse observes profuse after birth bleeding is to: a. call the woman’s primary health care provider. b. administer the standing order for an oxytocic. c. palpate the uterus and massage it if it is boggy. d. assess maternal blood pressure and pulse for signs of hypovolemic shock. ANS: C The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH). PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 6. When caring for a after birth woman experiencing hemorrhagic 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. urinary output of at least 30 mL/hr.