Fatime Sanogo vSim

When performing the postpartum examination, the nurse find the patient's fundus above the umbilicus and deviated to the right. What does the nurse know might be the cause of this finding?

A full bladder Rationale: When the bladder is full, it displaces the uterus upward and laterally, and the uterus is unable to contract effectively. The expected position of the uterus is midline. Retained placental tissue will interfere with contraction of the uterus but will not displace it. Constipation does not impact uterine tone or position.

The nurse reviews Ms. Sanogo's chart. Which factors place this pt at a higher risk for a postpartum hemorrhage?

Induction of labor with oxytocin (Pitocin) Baby weighed 9 lb (4082 g) Second degree laceration Prolonged second stage of labor Rationale: A large baby and prolonged second stage, induction with oxytocin, and laceration of the genital tract all place the patient at risk for postpartum hemorrhage. A positive sickle cell trait does not increase the risk for bleeding.

While assessing the patient's fundus, the nurse notes that with massage the uterus becomes firm, but then it relaxes again and the bleeding increases. Which of the following causes of excessive bleeding does the nurse suspect?

Retained tissue. Rationale: The presence of retained placental tissue prevents contraction of the uterine muscle and occlusion of vessels at the placental site. With uterine atony, the uterus does not firm up with massage. With a laceration there is excessive bleeding in the presence of a firm uterus. A hematoma is not related to the tone of the uterus.

The nurse is caring for a pt experiencing postpartum hemorrhage. After the nurse catheterizes the pt, the catheter drain 300 mL (10.1 oz) of clear yellow urine. Once the pt bladder is empty, what would the nurse do next?

Palpate the funds Rationale: Emptying the bladder will allow the uterus to contract and decrease the amount of bleeding. Reevaluating the firmness of the fundus will inform the nurse about the effectiveness of emptying the bladder in managing the hemorrhage.

The nurse calls the provider about Ms. Sanogo's bleeding. Which of the following items need to be included in the SBAR communication?

Blood loss of 800 mL in 25 mins Pulse tachycardia and weak Pain scale : 5/10 Rationale: Postpartum hemorrhage is an emergent situation impacting the physiologic well-being of the patient. The amount of blood loss, weak pulses, and the patient's pain are all significant findings to communicate in the SBAR report to the provider. The patient's bond with the newborn and limited English proficiency are not critical information to emphasize in this emergent situation.

Which of the following is consistent with the definition of a major obstetric hemorrhage?

Blood loss requiring transfusion of more than 5 units of blood. Rationale: The definition of a major obstetric hemorrhage is blood loss of more than 2,500 mL (84.5 oz) or blood loss requiring more than 5 units of transfused blood. Postpartum hemorrhage is defined as blood loss of 500 mL after vaginal birth or 1,000 mL after cesarean birth, but a more objective definition of postpartum hemorrhage would be any amount of bleeding that places the mother in hemodynamic jeopardy.

Ms. Sanogo has lost a significant amount of blood. The provider wants to be ready for a blood transfusion if needed. Which of the following blood samples does the nurse need to draw and send to the lab at this time?

CBC Type and cross-match Rationale: A blood sample must be drawn for type and cross-match so that blood can be readied in case of transfusion. A complete blood count is needed to document a baseline before a transfusion and to evaluate the effectiveness of the transfusion. An electrolyte panel, glucose levels, and fibrinogen and platelet counts are not useful at this time.

A patient is hemorrhaging after giving birth. When inspected, an area of the placenta was frayed. The provider suspects that placental fragments are retained within the uterus. What is the expected treatment for this condition?

Evacuation of the uterus followed by oxytocin (Pitocin) administration Rationale: Evacuation of the retained tissue from the uterus is the first step. This is usually done manually by the provider. Then oxytocin is administered to help maintain uterine contraction. Uterine massage with the administration of methylergonovine maleate or oxytocin administration followed by carboprost tromethamine administration will stimulate contraction of the uterus while the placental fragments are still inside. Uterine inversion is a medical complication, not an intervention.

Over a 10-min period, the nurse observes the following changes in Ms. Sanogo's VS: HR90 BP 100/60 SpO2 96% -> HR120 BP 90/50 SpO2 92%. Based on this data, the nurse is concerned that the pt is developing which condition?

Hemorrhagic shock Rationale: An increase in heart rate and decrease in blood pressure are consistent with the development of shock. These assessment parameters do not provide data consistent with presentation of the other conditions.

Which of the following contraindications to the administration of misoprostol (Cytotec) for treatment of a postpartum hemorrhage? (Select all that apply)

Hepatitis C Asthma Pulmonary or hepatic disease is a contraindication for the use of prostaglandin medications.

vSim

Introduce Yourself Wash Hands ID patient NIBP, Temp, Pulse Ox, Breath assessment Check Pupils Assess IV Administer 2mg butorphanol tartrate IV Check for blood, lochia and fluid on the bed Change/weigh the bed pads Assist patient into trendelenburg position Assess bladder status Assess perineum Palpate the fundus Educate the patient Fundal massage Call Provider Verify Dose and Administer 500ml/h oxytocin IV Administer 500ml LR over 30min. Assess IV site Give patient non-rebreather mask 10L Perform a straight cath Assess breathing again Call Provider Take CBC + Type and Screen blood sample Administer 800mcg misoprostol rectally Administer 5mg morphine IV Check pupils Phone provider End Scenario>Return to nurses station

When the nurse enters the room, Ms. Sanogo is in bed with the HOB elevated about 45 degrees. Ms. Sanogo says to the nurse, "Lot of blood.... is this OK?" What is the most appropriate response by the nurse?

Let me check your uterus and see what is happening. First I need to lower the HOB and have you lay flat while I do the exam Rationale: The fundus needs to be checked for firmness. When the head of the bed is elevated, the position of the uterus cannot be accurately assessed; thus, the head of the bed needs to be flat for this examination. Addressing the possible postpartum hemorrhage should be prioritized over cleaning up the blood. The nurse should assess the fundus before calling the provider.

Which of the following factors places a patient at risk for post partum hemorrhage?(Select all that apply)

Macrosomia Rapid Labor Maternal fever Oxytocin use during labor Rationale: Rapid labor, macrosomia, and oxytocin use during labor all place additional stress on the uterine muscle and may lead to muscle fatigue and failure of the muscle to effectively contract post-birth. Maternal fever indicating intrauterine infection may also impair the effectiveness of the uterine muscle to contract and control bleeding from the placental site. Preterm birth is not a risk factor for postpartum hemorrhage.

If Ms. Sanogo develops sx of hemorrhagic shock, what would be the priority interventions by the nurse?

Maintain adequate tissue perfusion Control blood loss Rationale: Controlling blood loss and maintaining tissue perfusion are the priorities. The patient needs to be stabilized before transfer. Antibiotics would be used for septic shock, and platelets are not useful in this situation. If a transfusion is ordered, it would be for packed cells to enhance the oxygen-carrying capacity of the blood and tissue perfusion.

The nurse monitoring Ms. Sanogo notices a large amount of vaginal bleeding. What would be the nurse's first action?

Massage the fundus Rationale: The first, immediate action is to massage the fundus in an attempt to stimulate uterine contraction and decrease the bleeding. Taking vital signs and calling the provider will not change the amount of blood being lost; however, these need to be done next. The IV contains medication and the rate cannot be indiscriminately changed.

After Ms. Sanogo's IV infusion of oxytocin has been started, what assessments need to be performed every 15 minutes for the next house or until her condition has stabilized?

Monitor bleeding Check fundus Take BP and HR Evaluate SpO2 Rationale: The oxytocin stimulates uterine contraction, and that contraction will decrease the amount of vaginal bleeding. Thus, bleeding and firmness of the fundus must be closely monitored. Blood pressure, heart rate, and SpO2 are important to monitor the patient's response to the blood loss. The patient's temperature is not directly impacted by the event.

A complication of postpartum hemorrhage is hemorrhagic shock. Which of the following signs would alert the nurse to the development of hemorrhagic shock?

Tachycardia, hypotension, and decreased urine output. Rationale: Tachycardia, hypotension, and decreased urine output are signs of poor tissue perfusion and the body's attempt to compensate to maintain vital functions. They are consistent with the development of hemorrhagic shock. Bradycardia, decreased hematocrit levels, and low platelets are late signs of the body's response to the blood loss and the consequences of hypovolemic shock.

Ms. Sanogo's husband asks, "Whats happening? What are you doing to help Fatime?" Which of the following is the best response by the nurse?

The uterus is not contracting properly. We are giving her meds to help the uterus contract and thereby control the bleeding.

Why should the patient's level of consciousness be assessed during management of postpartum hemorrhage?

To evaluate cerebral perfusion. Rationale: Level of consciousness will provide data about the adequacy of cerebral perfusion. With loss of blood volume, perfusion of vital organs, such as the brain, is at risk. The patient's cognitive abilities, understanding of the situation, and competence to make medical decisions are not parameters to assess cerebral perfusion.

Following the administration of misoprostol (Cytotec) for management of postpartum hemorrhage, which of the following is the priority nursing assessment?

Uterine tone Rationale: Continuous contraction of the uterus is the goal of postpartum hemorrhage interventions, and misoprostol is used to stimulate uterine contraction. Therefore, assessing uterine tone is the priority assessment to evaluate the effectiveness of this medication.

During the first 30 to 45 minutes of a postpartum hemorrhage, which of the following is the best parameter to estimate the amount of blood loss?

Visual quantification of the amount of bleeding. Rationale: Due to the increased blood volume of pregnancy, vital signs and urine output do not reflect bleeding until approximately 1,800 mL (60.9 oz) of blood has been lost. Therefore, early estimates of the degree of blood loss are based on observation or on weighing pads to quantify blood loss.