EAQ: Chapter 10: Nurse Care of Women with Complications After Birth
Which finding, along with bright red bleeding, would the nurse associate with a laceration when assessing the perineum of a patient who delivered vaginally? 1) Firm fundus 2) Displaced uterus 3) Dramatic loss of blood 4) Blue mass on the vulva
1) Firm fundus A constant trickle of bright red blood with a firm fundus are symptoms of a laceration. Bladder distension can cause the uterus to become displaced. A blue or purplish mass on the vulva is a sign of a hematoma. A dramatic loss of blood is usually associated with uterine atony.
Which assessment finding is associated with puerperal sepsis? 1) WBC count of 15000 2) Pulse of 60 beats/min 3) Fever of 38° C lasting for 2 days 4) Fever of 37.3° C lasting more than 24 hours
3) Fever of 38° C lasting for 2 days Fever of 38° C lasting for 2 days is a sign of sepsis. The other assessments listed are all expected aberrations.
Which postpartum complications require a clean-catch urine specimen for culture and sensitivity testing? Select all that apply. 1) Cystitis 2) Mastitis 3) Peritonitis 4) Endometritis 5) Pyelonephritis
1) Cystitis 5) Pyelonephritis Urinary tract infections such as cystitis and pyelonephritis require a clean-catch specimen for culture and sensitivity testing. Mastitis is breast inflammation and does not require a clean-catch specimen for culture and sensitivity testing to identify the type of infection. Peritonitis is inflammation of the peritoneum and does not require a clean-catch specimen for culture and sensitivity testing to determine the type of infection. A culture and sensitivity test of the uterine cavity is required for endometritis
Which complications may develop in a postpartum patient with a firm uterine fundus, severe uterine contractions, and bright red bleeding if not treated? Select all that apply. 1) Cystocele 2) Endometritis 3) Prolapsed uterus 4) Urinary incontinence 5) Deep venous thrombosis
1) Cystocele 3) Prolapsed uterus 4) Urinary incontinence Bright red bleeding and a firm uterus with severe uterine contractions indicate genital trauma. In addition to these symptoms, patients with genital trauma have periurethral lacerations. If a patient with these findings is not treated, it may lead to long-term effects such as cystocele, uterine prolapse, and urinary incontinence. Unrepaired periurethral lacerations cause the weakening of the supportive tissue between the bladder and the vaginal wall. This further causes the bladder to bulge into the vagina leading to the cystocele. Unrepaired periurethral lacerations also cause a weakening of the pelvic muscles leading to uterine prolapse. Urinary incontinence is a common finding of both cystocele and uterine prolapse. Endometritis is the inflammation of the vaginal wall, and it is not related to genital trauma. Deep vein thrombosis manifests as pain, calf tenderness, leg edema, color changes, and pain when walking.
The weight of a postpartum patient's perineal pad before applying is 15 g and after 1 hour is 600 g. Which condition would the nurse assess for based on this finding? 1) Hypovolemic shock 2) Puerperal infection 3) Normal postpartum state 4) Thromboembolic disorder
1) Hypovolemic shock A perineal pad weight of 1 g indicates 1 mL of blood loss. The initial weight of the perineal pad is 15 g and after saturation, it is 600 g. Therefore the weight of blood is 600 - 15 = 585 g = 585 mL. The patient has lost more than 500 mL of blood after vaginal delivery. This amount of blood loss puts the patient at risk for hypovolemic shock. Puerperal infection is the result of tissue trauma during labor from surgical incisions, or the open wound of the placental insertion site. As more than 500 ml of blood is lost there is hemorrhage, which is not a normal postpartum state. Thromboembolic disorders are caused by a blood clot in vein and not by hemorrhage.
The nurse is caring for a patient diagnosed with a large hematoma. Which clinical findings would the nurse assess for in the patient? Select all that apply. 1) Increased pulse rate 2) Increased temperature 3) Increased blood glucose 4) Increased blood pressure 5) Increased respiratory rate
1) Increased pulse rate 5) Increased respiratory rate A large hematoma causes excessive loss of blood. As a result, the patient's pulse and respiratory rates increase and the blood pressure decreases. Therefore the nurse should find that the patient has an increased pulse rate and respiratory rate. Elevated temperature is common in patients with puerperal sepsis. Large hematoma is not associated with an increase in blood glucose levels, as it does not affect insulin levels. A patient with a large hematoma would have reduced blood pressure. Therefore the nurse should check for a decrease in blood pressure, not an increase.
The nurse is caring for a patient with superficial venous thrombosis. Which intervention would the nurse expect to be beneficial for the patient? Select all that apply. 1) Light therapy 2) Application of heat 3) Elevation of the legs 4) Intravenous anticoagulant 5) Oral analgesic medication
2) Application of heat 3) Elevation of the legs 5) Oral analgesic medication Superficial venous thrombosis is characterized by the presence of a reddened hard vein in the lower leg. The application of heat helps relieve pain in the lower leg caused by superficial venous thrombosis. Elevating the legs promotes perfusion of the blood, facilitates venous drainage, and prevents swelling of the legs. Analgesic medication will assist with the pain associated with superficial venous thrombosis. Light therapy helps reduce the symptoms of depression; however, it does not help to alleviate the symptoms of superficial venous thrombosis. Intravenous anticoagulants are useful in the treatment of deep venous thrombosis.
Which assessment parameters would the nurse monitor in a patient with endometritis? Select all that apply. 1) Temperature 2) Bowel sounds 3) Respiratory rate 4) Uterine contour 5) Abdominal contour
2) Bowel sounds 5) Abdominal contour The nurse would monitor patients with endometritis for the absence of bowel sounds and distention of the abdomen; both conditions indicate the spread of infection. Uterine contour is assessed to check for distension which may indicate uterine atony. Uterine distention is not a manifestation of endometritis. Temperature and respiratory rate increase in a patient with puerperal infection, which is not related to endometritis.
Which condition in a postpartum patient would the nurse associate with lower extremity edema, calf tenderness and erythema, and a negative Homan's sign? 1) Muscle fatigue 2) Pulmonary embolism 3) Deep vein thrombosis 4) Superficial vein thrombosis
3) Deep vein thrombosis Deep vein thrombosis can involve veins from the feet to the femoral area and is characterized by tenderness, leg edema, color changes, pain when walking, and sometimes a positive Homan's sign, although the Homan's sign is not always reliable during the postpartum period because it is not specific to blood clots postpartum.
A postpartum patient with continuous vaginal bleeding is found to have placental fragments and small blood clots in the uterus on ultrasonography. Which intervention would be beneficial for the patient? 1) Perineal hygiene 2) Dilation and curettage 3) Administering vitamin K 4) An ice pack on the perineum
2) Dilation and curettage Retention of placental fragments in the uterus after delivery may result in postpartum hemorrhage. When the patient has continuous vaginal bleeding, dilation of the cervix and curettage helps remove small blood clots and placental fragments. Performing perineal hygiene would reduce the infection by flushing out the bacteria, but may not help to expel placental fragments and small blood clots. Applying ice packs on the perineum helps relieve pain. It does not help to remove placental fragments. Vitamin K enhances the process of blood clotting and prevents bleeding but does not help to expel the placental fragments from the uterus.
To prevent the risk of pulmonary embolism, which medication would the nurse expect to see on the patient's medication administration record? 1) Oxytocin (Pitocin) 2) Heparin (Lipo-Hepin) 3) Vitamin K (AquaMEPHYTON) 4) Methylergonovine (Methergine)
2) Heparin (Lipo-Hepin) Pulmonary embolism (PE) occurs as a result of the obstruction of the pulmonary artery by a blood clot. Heparin (Lipo-Hepin) is an anticoagulant that helps dislodge the blood clot and alleviates the symptoms of pulmonary embolism. Oxytocin (Pitocin) induces uterine contractions and helps treat uterine atony, but it does not lead to pulmonary embolism. Vitamin K (AquaMEPHYTON) enhances the process of blood coagulation. It can further complicate the symptoms of pulmonary embolism. Methylergonovine (Methergine) induces uterine contractions and helps treat uterine atony.
A postpartum patient who has undergone a vaginal delivery has redness and edema in the leg as well as pain while walking and flexing the foot. Which medication would the nurse anticipate being added to the patient's orders? 1) Oxytocin (Pitocin) 2) Heparin (Lovenox) 3) Calcium gluconate (Kalcinate) 4) Methylergonovine (Methergine)
2) Heparin (Lovenox) Deep venous thrombosis is a condition characterized by redness in the legs and an increase in the leg circumference by 2 cm. The patient will have pain while walking and flexing the foot. Heparin (Lovenox) is a long-acting anticoagulant drug used to treat deep venous thrombosis. Oxytocin (Pitocin) induces uterine contractions and relieves uterine atony. It does not help to reduce redness and edema of the legs. Calcium gluconate (Kalcinate) antagonizes the effects of the tocolytic drugs administered to relax the uterus. It does not prevent edema and redness of the legs. Methylergonovine (Methergine) helps contract the uterus, but it does not alleviate the symptoms of deep venous thrombosis.
Which assessment finding is a sign of hypovolemic shock? 1) Bradycardia 2) Hypotension 3) Warm and dry skin 4) Increased urine output
2) Hypotension Excess bleeding may cause fluid loss, which would result in hypovolemic shock. Patients with hypovolemic shock have a reduced amount of blood fluid that may cause hypotension. Hypovolemic shock manifests as tachycardia but not as bradycardia. As a result of loss of blood the patient's skin turns pale, cool, and clammy, but not dry and warm. As the patient has blood loss, the patient will have reduced hydration. Therefore the patient will have decreased urination.
The nurse is collecting data on a patient 24 hours after delivery and finds that the patient's skin is pale, cold, and clammy, and her pulse rate is 120 beats/min. Which condition is the nurse concerned about? 1) Endometritis 2) Hypovolemia 3) Pyelonephritis 4) Pulmonary embolism
2) Hypovolemia After delivery the patient has severe bleeding from which she may develop hypovolemia. Hypovolemia manifests as reduced fluid content, which in turn increases pulse and respiratory rate. As a result of loss of fluids the patient may also have pale, cold, and clammy skin. Endometritis is the inflammation of the inner lining of the uterus. Endometritis can cause fever and a high risk of infection in the patient. Increased pulse rate is not a manifestation of endometritis. Pyelonephritis is a bacterial infection, which affects the kidneys and is not associated with increased pulse rate. Pulmonary embolism occurs as a result of the obstruction of the pulmonary artery by a blood clot. It manifests as dyspnea and chest pain. Pulmonary embolism is not associated with hemorrhage.
The nurse assessing the vital signs of a newly delivered patient obtains a blood pressure of 117/63 mmHg and a pulse of 72 bpm. The nurse notes the baseline blood pressure and pulse on admission were 132/74 and 84. Which priority action should the nurse take? 1) Assess for respiratory rate 2) Perform a fundal assessment 3) Assess the quality of the lochia 4) Observe for symptoms of hypovolemia
2) Perform a fundal assessment The patient's blood pressure and pulse should be within 10% of the admission values. The priority action is to perform a fundal assessment. The fundus must be firm to compress the bleeding vessels at the placental site. The quality of lochia should be assessed after the fundal assessment. Observing lochia can help provide an estimate of blood loss, but is not a priority. Observing for symptoms of hypovolemia is not a priority; a physical assessment is the priority.
A woman who is 4 weeks postpartum informs the nurse at the outpatient clinic that her lochia remains red and she feels a heaviness in her pelvic area. The nurse assesses her fundus to be firm and at the umbilical level. Which condition would the nurse attribute these symptoms to? 1) Dehydration 2) Subinvolution 3) Cervical tear 4) Viral syndrome
2) Subinvolution Subinvolution is a slower-than-expected return of the uterus to its non-pregnant condition. Infection and retained fragments of the placenta are the most common causes. Typical signs of subinvolution include a fundal height greater than expected for the amount of time since birth; persistence of lochia rubra or a slowed progression through the three phases; and pelvic pain, heaviness, and fatigue. Dehydration, cervical tears, and viral syndrome are not associated with lochia and heaviness in the pelvic area.
The nurse is caring for a postpartum patient who has venous thrombosis. Which nursing intervention would be beneficial to the patient? 1) Instructing the patient to cross the legs. 2) Advising the patient to roll the stockings. 3) Assisting the patient with early ambulation. 4) Using nonpadded stirrups for episiotomy repair.
3) Assisting the patient with early ambulation. The nurse should assist the patient with early ambulation to reduce risk of thrombosis formation. Crossing of legs would impede blood flow. Therefore the nurse should instruct the patient to avoid crossing her legs. Rolling the stockings can impede blood flow, so the nurse should instruct the patient in the proper use of stockings. Padded stirrups help in episiotomy to repair and to prevent pressure on the popliteal angle.
The nursing instructor is teaching a group of student nurses about postpartum hemorrhage. Which statement made by a student nurse indicates effective learning? Select all that apply. 1) "Early postpartum hemorrhage occurs in patients 24 hours after birth." 2) "Patients who undergo vaginal delivery may lose up to 300 mL of blood." 3) "Hypovolemia and anemia occur in patients after postpartum hemorrhage." 4) "Patients who undergo cesarean section may lose more than 1000 mL of blood." 5) "Late postpartum hemorrhage occurs in patients within 6 weeks after delivery."
3) "Hypovolemia and anemia occur in patients after postpartum hemorrhage." 4) "Patients who undergo cesarean section may lose more than 1000 mL of blood." 5) "Late postpartum hemorrhage occurs in patients within 6 weeks after delivery." Loss of blood in patients after cesarean birth can be greater than 1000 mL. The major risk of hemorrhage is hypovolemic shock, which interrupts the supply of oxygen and nutrients as well as the removal of waste. Additionally, as a result of the excessive loss of blood, the patient becomes anemic. The loss of blood in patients after a vaginal birth is greater than 500 mL. Early postpartum hemorrhage occurs within 24 hours of birth, whereas late postpartum hemorrhage occurs after 24 hours and within 6 weeks after birth.
A postpartum patient with uterine atony and bleeding has not responded to medication. Which treatment strategy would be next in this situation? 1) A finger test 2) An episiotomy 3) A hysterectomy 4) A dilation and curettage
3) A hysterectomy A hysterectomy is beneficial for the patient who has bleeding in the uterus and is unresponsive to other measures. A hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries, fallopian tubes, and other surrounding structures. The finger test helps test the laxity of vaginal muscles, which determines whether a female has had intercourse for the first time. Performing this test would be inappropriate in this situation. An episiotomy is a surgical incision in the perineum to widen the opening of the vagina during childbirth and is inappropriate to perform in this situation. Dilation and curettage is performed in patients with postpartum hemorrhage to remove small blood clots and placental fragments, but not to treat bleeding in the uterus.
Which condition is a patient at risk for when suffering from a blood clotting disorder? 1) Septic shock 2) Cardiogenic shock 3) Hypovolemic shock 4) Anaphylactic shock
3) Hypovolemic shock Patients with a blood clotting disorder are at risk of bleeding in which they may lose excess amount of fluids from the body leading to hypovolemic shock. Septic shock may occur because of puerperal infection and is unrelated to the clotting disorder. Patients with pulmonary embolism, anemia, hypertension, and other cardiac disorders are at risk for cardiogenic shock. Patients with an allergy to certain drugs are at risk for anaphylactic shock.
Which postpartum complication is associated with assessment findings of difficulty breathing and 600 mL blood loss following vaginal delivery? 1) Septic shock 2) Cardiogenic shock 3) Anaphylactic shock 4) Hypovolemic shock
4) Hypovolemic shock Hypovolemic shock is caused by postpartum hemorrhage in which blood loss is greater than 500 mL, and when the patient has difficulty breathing during vaginal delivery. Septic shock occurs as a result of puerperal infection, which is a result of infection of the female reproductive organs during birth. Anemia or pulmonary embolism results in cardiogenic shock. Allergic reaction to an administered drug can cause anaphylactic shock.
A postpartum patient who was administered medication to relax the uterus during labor now has excessive bleeding as a result of a boggy uterus. Which medication would be beneficial for the patient? 1) Intravenous heparin 2) Subcutaneous insulin 3) Intravenous antibiotics 4) Intravenous calcium gluconate
4) Intravenous calcium gluconate The best treatment strategy in this situation would be administration of intravenous calcium gluconate. It counteracts the effect of tocolytic medications administered during labor to relax the uterus. Administering heparin would be inappropriate, as it does not cause the uterus to contract. Heparin is an anticoagulant, generally administered to prevent the risk of thromboembolic disorders. Insulin does not induce uterine contractions; it helps reduce blood sugar levels. Administration of intravenous antibiotics helps prevent various infections but has no effect on muscle tone of the uterus.
The nurse is caring for a postpartum patient with Subinvolution of the uterus. Which medication does the nurse expect to see in the patient's orders? 1) Heparin (Lovenox) 2) Warfarin (Coumadin) 3) Vitamin K (AquaMEPHYTON) 4) Methylergonovine (Methergine)
4) Methylergonovine (Methergine) Methylergonovine (Methergine) is used for the treatment of subinvolution of the uterus. It induces uterine contractions and helps maintain a firm uterus. Heparin (Lovenox) helps treat deep venous thrombosis and does not reduce subinvolution. Warfarin (Coumadin) is an anticoagulant that helps minimize the risk of embolism associated with thrombosis. Vitamin K (AquaMEPHYTON) helps antagonize the effects of warfarin (Coumadin).
Which assessment finding is associated with deep venous thrombosis? 1) Dyspnea 2) Hemoptysis 3) Shortness of breath 4) Positive Homan's sign
4) Positive Homan's sign Deep vein thrombosis is manifested as leg edema, calf tenderness, and pain while walking. Homan's sign is pain when the foot is dorsiflexed; pain while walking and positive Homan's sign indicate deep venous thrombosis. Dyspnea is shortness of breath, which is observed in pulmonary embolism. Hemoptysis is blood in the sputum and is a sign of pulmonary embolism. Shortness of breath can be caused by pulmonary embolism.
A postpartum patient with hemorrhage is kept on nothing by mouth (NPO) status until the primary health care provider evaluates the situation for which reason? 1) Nausea and vomiting may also occur. 2) There may be a need for opioid analgesics. 3) Subinvolution of the uterus may be occurring. 4) There may be a need for general anesthesia.
4) There may be a need for general anesthesia. The patient who has postpartum hemorrhage should be kept on nothing by mouth (NPO) status, as the patient may need general anesthesia for the treatment of lacerations. A patient with hemorrhage does not typically have nausea or vomiting and would not require NPO status. Opioid analgesic drugs can be given orally and do not require NPO status. Subinvolution is slower-than-expected return of the uterus to the non-pregnant state. Subinvolution does not require NPO status as it does not cause excessive bleeding.