Relias: Nursing Care of the Patient with Obstetric and Postpartum Hemorrhage Assessment

A hemorrhage risk assessment is completed: SATA 1. Upon admission 2. Throughout labor, as risk factors develop 3. Prior to birth 4. Hourly in labor

1. Upon admission 2. Throughout labor, as risk factors develop 3. Prior to birth

Ms. Johnson, a 38-year-old G3P2 at 37 6/7 weeks' gestation, presents in early labor. She reports having uterine fibroids with this pregnancy and a history of PH with her last birth. The nurse is aware that Ms. Johnson's admission risk factors for PP include which of the following? Select all that apply. Uterine fibroids Gestational age <38 weeks Greater than 1 vaginal birth Prior PPH

Prior PPH Uterine fibroids PPH risks include uterine fibroids and a history of hemorrhage. Gestational age is not a hemorrhage risk factor. Greater than 4 vaginal births is a risk factor, so it is not considered a risk for this patient.

Ms. Brown's heart rate now reads 128 BPM on the pulse oximeter. Which of the following responses from the charge nurse indicates an understanding of early warning signs potentially preceding maternal collapse? Select an. answer. "Let's watch it for a little bit while you finish your charting." "Can you manually verify that reading, assess your patient, and call the provider for a bedside assessment?" "Most mothers have an increased heart rate after birth if their pain is not well-managed." "Take the pulse oximeter off for a little bit, as that has nothing to do with her bleeding."

"Can you manually verify that reading, assess your patient, and call the provider for a bedside assessment?" Abnormal vital signs, including pulse oximeter readings, indicate a need for immediate confirmation, bedside evaluation, and agreement of reassessment time frames. Differential diagnoses should also be considered.

Which of the following nursing interventions should be performed in collaboration with other interventions during a Stage 1 obstetric hemorrhage? Select all that apply. 1 Keep the patient warm using warmed fluids and warmer devices. 2 Directy quantify blood loss (OBL) and communicate cumulative QBL. 3 Aggressively replace blood loss with an equal amount of crystalloid fluids. 4 Avoid the use of a bladder catheter to limit the risk of infection.

1 Keep the patient warm using warmed fluids and warmer devices. 2 Directy quantify blood loss (OBL) and communicate cumulative QBL.

Ih the setting of PPH, maternal vital signs may not be impacted until after what percentage of total blood volume loss? Select an answer. 5% 10% 20% 50%

20% Maternal vital signs may remain stable during the initial stages of PPH, with tachycardia or hypotension only appearing after the loss of 20%-25% of circulating blood volume or > 1500 mL.

Ms. Sato delivered by cesarean birth yesterday. Her CBC drawn 24 hours postbirth shows a platelet count of 60,000/L, and her blood pressures are elevated well above her baseline. The nurse assesses the patient to find the funds is firm, the lochia is heavy and thin in consistency, and the incision is showing some oozing through the dressing. The nurse also notices blood collecting under the clear adhesive IV dressing at the insertion site. The nurse calls the physician and relays the concern that the patient is showing signs of disseminated intravascular coagulation (DIC). Based on Ms. Sato's case, which of the 4 Ts of PPH is likely causing the bleeding? Select an answer. Uterine atony (tone) Vaginal lacerations (trauma) Retained placental fragments (tissue) Coagulopathy (thrombin)

Coagulopathy (thrombin) The patient is exhibiting manifestations of preeclampsia that include elevated blood pressure and decreased platelet count. Further lab work is indicated to evaluate the other coagulation factors but should not delay treatment. Reduced clotting factors can accompany thrombocytopenia in patients with preeclampsia and is manifested by oozing at the incision site, heavy, thin lochia and a firm uterus. This is an acquired coagulopathy and falls into the category of thrombin for the 4 Ts.

Which are the components of the "lethal triad" in hemorrhage? Select an answer. Bleeding, bleeding, and more bleeding Hypothermia, acidosis, and coagulopathy Hypothermia, hypotension, and bradycardia Diuresis, fluid overload, and pulmonary edema

Hypothermia, acidosis, and coagulopathy The lethal triad in hemorrhage is hypothermia, acidosis, and coagulopathy. Although identifying and treating the source of blood loss is critically important in managing the patient with postpartum hemorrhage (PPH), one must also focus on correcting the secondary physiologic consequences of excessive hemorrhage, sometimes called the "lethal triad*: hypothermia, acidosis, and coagulopathy.

Ms. Diaz, a G4P3, had a vaginal birth of a baby girl 45 minutes ago, with a quantitative blood loss (QBL) of 456 mL. She is breastfeeding her baby and reports that she feels like she is bleeding. The nurse assesses the amount of blood, sees that it appears to be a large amount, and measures it to be 200 mL. Cumulative QBL is now 656 mL. Appropriate initial nursing interventions include (select all that apply): Placing vaginal packing Fundal massage Evaluating vital signs Notifying provider of assessments Providing warm blankets

Fundal massage Evaluating vital signs Notifying provider of assessments Providing warm blankets Fundal massage and assessment, evaluating vital signs, and communicating with the provider are appropriate initial nursing interventions. Vaginal packing should not be placed unless other evaluations and interventions have first occurred, and it is a provider intervention. Hypothermia worsens hemorrhage outcomes, and the patient should be kept warm.

During Ms. Lee's obstetric hemorrhage, the massive transfusion protocol is initiated. Lab work shows a hemoglobin of 6.4 and hematocrit of 19.8%. Based on the nurse's understanding of the effect of PRBC administration on the hemoglobin level, what level does the nurse estimate the hemoglobin to be after 3 units of PRBCs are administered? Select an answer. • Hemoglobin 9.4 • Hemoglobin 12.4 • Hemoglobin 8.4 • Hemoglobin 7.9

Hemoglobin 9.4

CASE 2 | QUESTION 1 Ms, Williams' QBL was 800 mL at birth, and she continued bleeding during recovery, Her cumulative QBL is now 1750 mL, a Stage 3 OH. The team prepares to move Ms, Williams to the OR, and the nurse realizes that Ms, Willams' bladder has not been emptied. The nurse understands that ambiving the bladder is an early intervention. What is the bost action after this finding? Select an answer, Continue with the hemorrhage protocol and complete Stage 3 interventions only. Prepare to add this information to a risk report and an email to the manager later. Speak up for safety and suggest to the team leader that a catheter should be placed. Remember next time to empty the bladder sooner.

Speak up for safety and suggest to the team leader that a catheter should be placed. It is appropriate to suggest or introduce interventions that were missed or not yet utilized from previous stages during later stages. Speaking up about the missed intervention is the best action, protecting patient safety. This would also be helpful information to give in a debrief later, as well as an email so others can learn from this missed opportunity, but the most important would be to provide the information to be used for the current patient.

The nurse can quickly determine that coagulopathy has not complicated Ms. Brown's hemorrhage by assessing which of the following? Select all that apply. The blood collecting on the pads that is clotting quickly Seeing there is no oozing from IV sites Drawing coagulation studies and waiting for results Estimating the rest of the blood loss

The blood collecting on the pads that is clotting quickly Seeing there is no oozing from IV sites While QBL, clinical signs, and lab values can all help drive interventions and confirm the presence of coagulopathy, clotting of blood and lack of oozing from IV sites can quickly indicate normal coagulation pathways. Drawing labs is helpful, but waiting for results should not delay interventions. Quantified blood loss should replace estimated blood loss whenever possible.

CASE 2 | QUESTION 1 Ms. Goldberg delivered a 4700 g (10 lb 6 oz) baby girl an hour ago and questioned the nurse, "Why do you have to keep pushing on my belly? It really hurts!" The nurse responds by stating, "Your uterus is not firming up as well as it should be, so I am trying to help it by encouraging it to contract so that you don't bleed too much " Based on Ms. Goldberg's case, which of the 4 Ts of PPH is likely causing the bleeding? Select an answer. Uterine atony (tone) Vaginal lacerations (trauma)' Retained placental fragments (tissue) Coagulopathy (thrombin)

Uterine atony (tone) Uterine atony is the most common reason for PPH and falls under T for tone. A uterus that does not firm up is called a "boggy" uterus, and requires fundal massage to aid in firming up. A boggy uterus is more likely to bleed than one that is firm and contracted. To perform a fundal massage, place 1 hand on the lower uterine segment for support and the other hand on the top of the fundus using a massaging motion.

After a vaginal birth, the fluid in the under-buttocks drape is marked at 200 mL prior to placenta. The total amount in the drape when the drape is removed at the end of the birth is 550 mL The weight of the blood-soaked items is 450 g. The dry weights of those items total 375 g. The nurse calculates the quantitative blood loss (QBL). What is the total QBL for the birth? Select an answer. • 550 mL O 350 mL • 425 mL O 75 mL

• 425 mL

Ms. Lee has lost a cumulative QBL of 1230 mL and is experiencing a Stage 2 hemorrhage. She has received oxytocin and methylergonovine, her bladder has been emptied, warm blankets applied, and the provider is massaging her fundus. Her vagina and cervix have been inspected for lacerations, and none were found. Uterine atony is suspected as the etiology. The nurse administers 1000 mL intravenous Lactated Ringer's via fluid warmer, and the provider is considering transfusing blood. The nurse understands which of the following are appropriate nursing interventions during Stage 2 hemorrhage? Select all that apply. • Continue with aggressive IV fluid resuscitation rather than blood products. • Provide second large bore IV access. • Suggest the use of a uterine tamponade balloon or intrauterine vacuum-induced device. • Change to estimated blood loss (EBL) because other staff are performing other tasks.

• Provide second large bore IV access. • Suggest the use of a uterine tamponade balloon or intrauterine vacuum-induced device. Blood products should be introduced if more IV fluids are needed. IV fluid resuscitation alone puts the patient at further risk for complications related to dilution and fluid overload. A second, large bore IV access site is recommended in Stage 2. Uterine tamponade balloon or an intrauterine vacuum-induced device is appropriate when uterine atony is suspected as the etiology. QBL should always be used in place of EBL.

Ms. Martinez is a 20-year-old G1P0 who is pushing at +3 station. The nurse prepares for a vaginal birth and understands which of the following are part of the active management of the third stage of labor (AMTS), aimed at decreasing obstetric hemorrhage? Select 2 answers. 1. Administration of oxytocin after birth 2. Administration of methylergonovine maleate postbirth 3. Administration of misoprostol postdelivery 4. Controlled cord traction, as needed, by the provider 5. No medications unless the patient shows signs of obstetric hemorrhage

1. Administration of oxytocin after birth 4. Controlled cord traction, as needed, by the provider Administration of misoprostol or methylergonovine maleate will treat PH but is not recommended routinely to prevent it. Oxytocin is used routinely; however, the World Health Organization (WHO) recommends the following for prevention of PPH: • Offer a uterotonic agent immediately after birth; oxytocin is the preferred medication. Delay clamping the cord for at least 1-3 minutes to reduce rates of infant anemia. • Perform controlled cord traction as required; the WHO recommends the use of gentle, controlled cord traction only by skilled birth attendants. (American College of Nurse Midwives 2017)

Question 41 of 63 Ms. Romano just delivered a male infant vaginally without complication. After delivery of the placenta, there is brisk bleeding from a laceration in the right vaginal sulcus. The vaginal laceration is repaired, and the vaginal bleeding decreases to minimal. Quantitative blood loss is 810 mL. Thirty minutes later, she states that she feels very tired. The nursing assessment finds the uterine funds is firm, and there is scant vaginal bleeding. Her BP is 80/40 mm Hg, and her pulse is 112 BPM. What would be an appropriate next step? Select an answer. Notify the provider and expect an order to type and cross the patient for 2 units of PRBCs. Since the fundus is firm and the bleeding is scant, continue to monitor symptoms. • Draw CBC and wait for results to decide if the blood products are required. O Do nothing until her pulse becomes > 120 BPM, which is when it becomes concerning.

Notify the provider and expect an order to type and cross the patient for 2 units of PRBCs.

The nurse weighs the large clot and pads from underneath Ms. Brown and calculates her cumulative QBL to be 1270 mL (600 mL at birth, 270 mL from the last pad change, and 400 mL from this clot and pad change). BP 99/67, HR 110BPM, Temp 37.1, RR 18/min, SpOs 97% The nurse understands the next step should be (select an answer): a. Wait 30 minutes and reevaluate vital signs. b. Call the postpartum nurse for transfer. c. Assist the patient to the bathroom to void immediately. d. Notify the provider, and initiate hemorrhage interventions.

Notify the provider, and initiate hemorrhage interventions. Physiologic changes in pregnancy help compensate for blood loss, and vital sign changes may not be significant until over 1500 mL has been lost. QBL > 1000 mL requires communication to the provider and interventions to be initiated. The patient is presently not appropriate for transfer, should not get out of bed to the bathroom, and the nurse should not wait 30 minutes for the next evaluation. Hemorrhage interventions, such as communication of QBL to the provider, fundal massage, evaluation for etiology, and uterotonic medications, should begin.

Ms. Smith is a 17-year-old primipara, Non-Hispanic Black woman who dropped out of s Ms. Smith gave birth vaginally 20 minutes ago. After birth, she began to have increased nurse and said, "Is this bleeding normal? I'm afraid I'm going to die." The nurse is aware that which health disparity may affect Ms. Smith's health outcome? Select an answer. a. Being a Non-Hispanic Black woman b. Living with her mother c. Growing up in a wealthy family d Lacking a secondary education The nurse is aware that which social determinant of health may affect Ms. Smith's health outcome? Select an answer. a. Being a Non-Hispanic Black woman b. Living with her mother c. Growing up in a wealthy family d Lacking a secondary education

Q1 Being a Non-Hispanic Black woman Q2 d Lacking a secondary education A Non-Hispanic Black Woman is at a higher risk for maternal mortality. A patient living with her mother has no relevance in health outcomes as long as it is a safe environment. A patient coming from a wealthy upbringing actually has a better chance at good health outcomes. Education is a social determinant of health, and Ms. Smith has dropped out of school, thereby increasing the risk of poor outcomes.

The charge nurse is called to the room after Ms. Gupta's birth to assist with hemorrhage management. There is a large amount of blood in the under-buttocks drape, and oxytocin is being bolused intravenously at a rate of 334 mL/ hr. The bedside nurse reports that Ms. Gupta's hemorrhage risk assessment was high, and the provider is concerned about the amount of bleeding she is currently having. The nurse understands which of the following interventions will provide the team with the most timely information to direct appropriate care? Select an answer. Drawing a STAT CBC and waiting for results to become available. Taking a set of vital signs and comparing them to baseline. Quantifying cumulative blood loss through measurement. Asking the provider how they are feeling about the situation.

Quantifying cumulative blood loss through measurement. Quantified blood loss (QBL) is the most helpful, real-time trigger for determining interventions. Lab results may take too long and are likely not equilibrated to the patient's real time status. Vital signs may not evidence a change until over 1500 mL of blood loss. Vital sign changes can be appropriate triggers for interventions but are likely to remain stable initially due to maternal compensatory mechanisms. While the bedside team's intuition is an important tool, it should not override standardized, quantitative tools such as QBL.

Ms. Gupta experienced a significant postpartum hemorrhage after birth. Which of the following statements are appropriate during the debriefing process? Select all that apply. a. We did a great job with closed-loop communication." b. 'Linda, why didn't you get the vitals and blood loss before calling the provider? He had to wait on the phone for us to calculate it." c. We were missing the uterine tamponade balloon from our hemorrhage cart. Sara, can you make sure the cart is fully stocked and clarify with the team who is responsible for ongoing stocking and checking the hemorrhage cart?" d. "Can we work on getting tranexamic acid readily available on override? It felt like a really long time to receive this from the pharmacy.*

a c d After the PH, it is important to debrief with the healthcare team. The Alliance for Innovation on Maternal Health (AIM) recommends that debriefing should be part of the unit culture to reinforce successes and identify opportunities (Main et al 2015). While debriefing does not need to be a formal, structured event, it should include the following elements: What went well? How did the following affect team performance? • Team Leadership • Situational Awareness • Mutual Support • Communication Did we have all the necessary equipment and resources? Were there any lessons learned? What goals for improvement were identified? What could we do differently next time? Debriefing should be nonjudgmental and refrain from accusations such as, "Linda, why didn't you get the vitals and blood loss before calling the provider?" A better way to phrase that concern is, "Next time before we call the physician, let's make sure we have the most recent set of vitals and QBL to report."

Ms. Schmidt is a 27-year-old G1P1 whose pregnancy was complicated by gestational diabetes with fetal macrosomia and polyhydramnios. Postbirth, Ms. Schmidt developed uterine atony, which was initially unresponsive to fundal massage medical therapy, and conservative nonsurgical attempts to control hemorrhage. The QBL is 2150 mL, with BP 80/40 mm Hg, and pulse is 130 BPM, weak and thready. The decision is made to proceed with an emergency hysterectomy. What orders can you anticipate next from the provider? Select 2 answers. a. Activate the massive transfusion protocol b. Draw a STAT CBC with platelets, waiting on results to guide blood replacement c. Draw a disseminated intravascular coagulopathy panel d. Administer massive crystalloid resuscitation equal to 3 times the patient's QBL

a. Activate the massive transfusion protocol c. Draw a disseminated intravascular coagulopathy panel Given the patient's significant blood loss, the nurse should anticipate orders for the immediate activation of an MT and drawing a DIC lab panel. The patient with this volume of blood loss may be coagulopathic, 'even though it may not be presently apparent. It is not appropriate to delay transfusion while awaiting lab results, as the patient's condition will likely deteriorate. Ms. Smith is clearly in need of volume replacement; however, replacing large amounts of blood loss with excessive crystalloid may potentially worsen coagulopathy. Instead, attention should be focused on the early replacement of blood products with limited crystalloid resuscitation and identifying any coagulopathy.

Ms. Diaz expels a grapefruit-sized clot. The nurse massages Ms. Diaz fundus and informs the physician that the patient has entered Stage 2 of hemorrhage. The physician states, "Let's just watch her over the next hour." What should the prudent nurse do? Select an answer. • State that for a Stage 2 hemorrhage, the protocol recommends that the provider evaluates the patient and orders a uterotonic. O Follow the physician's order, as it is the physician's call, not the nurse's. • Tell the patient that the doctor does not seem to think her bleeding is concerning. • Ask the senior nurse what to do, and follow that advice.

• State that for a Stage 2 hemorrhage, the protocol recommends that the provider evaluates the patient and orders a uterotonic.

The nurse is aware that which of the following interventions are aimed at obstetric hemorrhage (OH) prevention for all births? Select all that apply. a. Recommending prophylactic oxytocin for active management of the third stage of labor. b. Bringing the hemorrhage cart and all uterotonic medications to every birth. c. Visually estimating blood loss after the birth of the baby and placenta. d. Team awareness of the patient's pre-birth OH risk level.

a. Recommending prophylactic oxytocin for active management of the third stage of labor. d. Team awareness of the patient's pre-birth OH risk level. Prophylactic oxytocin administration and risk assessment are hemorrhage prevention strategies recommended for all births. Presence of a hemorrhage cart and use of uterotonics are not recommended for every birth but should be readily accessible for all births and should be present in births assessed to be at high risk for hemorrhage. Visual EBL should be replaced by QBL whenever possible.

Ms. Gupta, a 27-year-old G4P4, delivered vaginally 1 hour ago. Her QBL at birth was 475 mL, and her admission lab work is as follows: HGB 10.7 HCT 32.8% Platelets 230,103 Thirty minutes later, the nurse recognizes the PH and finds an atonic uterus. The healthcare team is alerted. After fundal massage, uterotonic medications, and other interventions, an additional 1250 mL of blood loss is identified with continued bleeding. The physician activates the MT. The nurse prepares to administer blood products and draw additional lab work ordered by the physician. The nurse recognizes an important intervention and rationale is (select an answer): a. Drawing lab work to check liver enzymes and a CBC and coagulation panel to direct product transfusion. b. Using the blood warmer to deliver the blood products to prevent hypothermia. c. Awaiting cross-matched blood to arrive before starting the blood transfusion to decrease an adverse reaction. d. Bolusing with 2 liters of IV crystalloids to increase the patient's ability to clot.

b. Using the blood warmer to deliver the blood products to prevent hypothermia. Blood warmers prevent the negative effects of hypothermia/hypoperfusion and acidosis (Jackson, DeLoughery 2018). Patient-warming devices may also be used for this purpose. Hypothermia can inhibit clotting by: • Decreasing activity of coagulation enzymes • Decreasing platelet and fibrinogen synthesis • Increasing fibrinolysis Checking for blood counts and coagulopathies is important; however, transfusion should not wait for results of labs, and liver enzymes are not a priority. Prevention of hypothermia takes precedence, and a nurse can prepare the blood warmer. Delay in the administration of blood products should be avoided, even if the blood is not cross-matched. Once the cross-match has occurred, type-specific blood products are preferred. The utilization of large amounts of IV crystalloids can be harmful to patients undergoing massive blood loss. The excess fluid causes dilutional coagulopathy, clot disruption, and decreased blood viscosity (Chatrath et al 2015).

Ms. Gupta delivered 4 days ago via cesarean birth, which was complicated by a significant postpartum hemorrhage. Ms. Gupta required 6 units of PRBCs. She spent 1 night in the ICU, and she should be discharged today as expected. Which outcome is reported as a severe maternal morbidity indicator? a Critically low hematocrit b Postpartum hemorrhage c Blood product transfusion D Discharge on day 4 postcesarean birth

c Blood product transfusion Severe maternal morbidity indicators for maternal outcomes are derived from 21 International Statistical Classification of Diseases and Related Health Problems (ICD) billing codes. Blood product transfusion is considered a severe maternal morbidity indicator. Neither a postpartum hemorrhage diagnosis or an ICU admission without transfusion is considered a severe maternal morbidity indicator. The low hematocrit will aid in the decision to transfuse the patient but is not considered a severe maternal morbidity on its own.

Question 15 of 63 The nurse reports that the quantitative blood loss (QBL) from the under-buttocks drape after the vaginal birth is 745 mL after dry weights and pre-placental fluids have been subtracted. Prior to the provider leaving the room, the obstetric team decides to re-evaluate bleeding, fundal height, and vital signs. The decision for heightened surveillance is made because: Select an answer. a. The team mistakenly diagnoses a hemorrhage despite the fact that QBL is <1000 mL. b. Cumulative QBL is not accurate enough to diagnose obstetric hemorrhage. c. The team correctly identifies 745 mL as an abnormal amount of blood loss for a vaginal birth, warranting close monitoring. d. Some providers are more cautious than others, and management depends on the individual provider.

c. The team correctly identifies 745 mL as an abnormal amount of blood loss for a vaginal birth, warranting close monitoring. Though the standard definition of a hemorrhage is blood loss >1000 mL, blood loss >500 mL is abnormal in a vaginal birth and warrants close monitoring. This is considered a Stage 1 hemorrhage on AWHONN's hemorrhage staging system. Initial interventions to manage hemorrhage are appropriate after 500 mL blood loss in a vaginal birth (Association of Women's Health, Obstetric and Neonatal Nurses 2021a). QBL should be the main trigger to help guide management of a hemorrhage. Standardized protocols help limit variances due to different providers.

Question 42 of 63 After administration of oxytocin, methylergonovine maleate, and carboprost, Ms. Petrov's uterine atony is controlled; however, she continues to bleed. Her blood loss is categorized as a Stage 2 hemorrhage. Her uterus is firm, midline, and at the umbilicus. Which medication should the nurse anticipate being ordered next? After administration of oxytocin, methylergonovine maleate, and carboprost, Ms. Petrov's uteri she continues to bleed. Her blood loss is categorized as a Stage 2 hemorrhage. Her uterus is umbilicus. Which medication should the nurse anticipate being ordered next? Select an answer. a. Oxytocin b. Methylergonovine maleate c. Carboprost d. Tranexamic acid

d. Tranexamic acid If a PPH continues despite treatment, the risk of coagulopathy increases, at which time TXA may be appropriate. TXA inhibits fibrinolysis and may reduce bleeding when there are coagulation abnormalities. TXA is not used to treat uterine atony and should not be an initial treatment of PPH (California Maternal Quality Care Collaborative 2017). Because the patient's uterine atony has been controlled, administration of uterotonic drugs such as oxytocin, methylergonovine maleate, carboprost, or misoprostol would not be appropriate.

Question 1 of 63 During a cesarean, the provider communicates that the drapes have been suctioned out prior to the delivery of the placenta. The nurse notes the suction canister has 350 mL of blood-tinged fluid in it. The nurse quickly switches to a new suction canister prior to the delivery of the placenta. As the fascia is closed, the provider again suctions the drape, and the nurse notes 600 mL of blood in the new canister. Twenty sponges in 4 sponge counter bags are weighed with a total amount of 400 g. The nurse knows the dry weight of 20 sponges and 4 counter bags is 250 g. What amount of quantitative blood loss does the nurse record for this birth? Select an answer. • 600 mL 1350 ml • 750°mL • 1100 mL

• 750°mL

Question 58 of 63 A 32-year-old G2P2 had a vaginal birth after a prolonged labor induction for preeclampsia. The baby weighed 4000 g (8 lb 13 oz), and the patient sustained a second-degree perineal laceration, which is being repaired. As the repair is being completed, the nurse becomes concerned about the amount of additional blood on the under-buttocks drape but observes that the patient's vital signs are normal. Which of the following statements is most accurate? Select an answer. • Between 10%-20% of a woman's blood volume may be lost before the vital signs are affected. • Abnormal bleeding should not be reported until it is accompanied by vital sign changes. © Large amounts of blood loss will be evident in blood pressure readings within 5 minutes. • Women with preeclampsia are better able to tolerate blood loss given their expanded total blood volume.

• Between 10%-20% of a woman's blood volume may be lost before the vital signs are affected.

Ms. Nguyen has continued uterine atony and a Stage 1 hemorrhage after her vaginal birth, despite administration of methylergonovine maleate. Which of the medications listed might the nurse expect the physician to order next? Select an answer. • A second dose of methylergonovine maleate • Carboprost • Terbutaline • Tranexamic acid

• Carboprost If oxytocin and methylergonovine maleate have been unsuccessful in treating her uterine atony, the next medication to administer is carboprost. Tranexamic acid (TXA) will be the medication of choice in a Stage 2 hemorrhage, so it may be requested after the carboprost (American College of Obstetricians and Gynecologists 2020; Association of Women's Health, Obstetric and Neonatal Nurses 2021). Terbutaline is a tocolytic medication that would relax the uterus and is contraindicated as the goal of treatment is to contract the uterus,

Which of the following are tools used to quantify blood loss? SATA • Dry weight chart • Calibrated drapes • Blood pressure cuff Portable scale

• Dry weight chart • Calibrated drapes Portable scale

Ms. Gupta is undergoing a massive transfusion protocol (MT due to an obstetric hemorrhage. The nurse is aware that the most common electrolyte abnormalities related to MTP are: Select 2 answers. • Hyperkalemia • Hypocalcemia • Hypercalcemia • Hypomagnesemia

• Hyperkalemia • Hypocalcemia Patients undergoing blood product transfusion may develop electrolyte abnormalities--most commonly hyperkalemia and hypocalcemia. Stored red blood cells release potassium, and rapid transfusion of multiple units may result in hyperkalemia and cardiac arrhythmias. Hypocalcemia may also occur as the citrate binds to ionized calcium levels in the blood. Hypomagnesemia may accompany hypocalcemia.

Ms. Garcia delivered vaginally, and the active management of the third stage of labor was provided. Despite these interventions, the patient continues to bleed, and a Stage 1 obstetric hemorrhage is identified. The physician ordered methylergonovine maleate. In which of the following conditions would methylergonovine maleate be contraindicated? Select an answer. • In a patient with a hypertensive disorder In a patient with a history of asthma • In a patient with systemic lupus erythematosus • There are no contraindications for methylergonovine maleate

• In a patient with a hypertensive disorder Methylergonovine maleate is contraindicated in patients with hypertension, heart disease, or hypersensitivity to the medication. Asthma and systemic lupus erythematosus are not contraindications to the administration of methylergonovine maleate.

Ms. Brown delivered 30 minutes ago. Initially, the fundus was firm with only some "trickling" from the vagina. During the second 15-minute fundal check, the nurse notes the bleeding is filling a pad quickly. The funds remains firm, but the bleeding remains bright red at a steady trickle. What is the probable etiology of the bleeding? Select an answer. • Retained placenta • Placenta previa • Laceration • Hematoma

• Laceration A laceration presents with bright red bleeding or trickles, with no relation to fundal tone. A retained placenta typically presents with uterine atony and darker red bleeding. A hematoma presents with increasing pain and swelling in the absence of visible bleeding. A placenta previa is resolved at cesarean birth and is not applicable postpartum.

Early nursing interventions in a Stage 1 hemorrhage include: Select an answer. • Administering uterotonics, drawing labs, and moving to the OR • Massaging the fundus, ambulating the patient, and quantifying blood loss • Massaging the fundus, emptying the bladder, and quantifying blood loss O Evaluating vital signs, assessing for cervical lacerations, and administering IV fluids

• Massaging the fundus, emptying the bladder, and quantifying blood loss

Question 51 of 63 The following 2 medications have similar mechanisms of action, and if 1 is ineffective in controlling obstetric hemorrhage, it is unlikely the other will be effective: • Oxytocin and tranexamic acid • Misoprostol and carboprost • Misoprostol and methylergonovine maleate • Methylergonovine maleate and carboprost • Oxytocin and carboprost

• Misoprostol and carboprost

Ms. Nguyen is day 3 postcesarean birth. The postpartum nurse has been watching her lochia amount closely as it seems to have increased over the last several hours. The uterine tone is boggy, and when massaged, small clots are expressed, firming up the uterus. The nurse reviews the delivery note and reads that the placenta was manually removed in pieces during Stage 3. The nurse reports the findings to the physician. Based on Ms. Nguyen's case, which of the 4 Ts of postpartum hemorrhage is likely causing the bleeding? Select an answer. • Uterine atony (tone) • Vaginal lacerations (trauma) • Retained tissue (tissue) • Coagulopathy (thrombin) Continue

• Retained tissue (tissue) Continued uterine bleeding due to the retained placenta fragments can lead to a repeating cycle of uterine distension and atony. Following birth, the placenta should be inspected to confirm the specimen is intact and complete. In Ms. Nguyen's case, it was not intact, and it was difficult to tell if it was complete. Retained placental fragments are a common cause for secondary (late) PH in patients and typically presents with renewed, heavy bleeding long after birth. The diagnosis of retained placental tissue is most frequently made with ultrasound visualization of an echogenic mass in the endometrium. The nurse should prepare the patient for possible surgical exploration or dilation and curettage (D&C) to remove the placental fragments).

A cumulative quantitative blood loss after a vaginal birth that is 600 mL is considered what stage of hemorrhage? Select an answer. • Severe hemorrhage • Stage 1 hemorrhage • Stage 3 hemorrhage • Is not staged because it is <1000 mL

• Stage 1 hemorrhage

Question 26 of 63 Ms. Williams had an operative vaginal birth assisted with forceps 2 hours ago. Initially, her bleeding was heavy but then slowed once the third-degree perineal laceration was repaired. Now Ms. Williams is reporting vaginal pain and intense rectal pressure rated a 9/10. The nurse assesses her funds and finds it firm. The lochia is minimal. The patient's vital signs are: BP 92/54 mm Hg, HR 110 BPM, R 22, T 37.2°C (99.0°F). She is diaphoretic and pale. Based on Ms. William's case, which of the 4 Ts of postpartum hemorrhage is likely causing the pain? • Uterine atony (tone) • Vaginal hematoma (trauma) • Retained placental fragments (tissue) • Coagulopathy (thrombin)

• Vaginal hematoma (trauma) Ms. Brown is exhibiting manifestations of hypovolemia without visual evidence of bleeding or uterine atony. She experienced an operative vaginal birth that places her at increased risk for soft tissue trauma. The patient reports pain in the vaginal and perineal area and rates her pain a 9/10. The nurse should recognize the signs and symptoms of a hematoma and look for firm, discolored swelling in the perineal and vaginal area and report the finding to the physician for evaluation. A hematoma may expand greatly and become an obstetric emergency, particularly if a vessel continues to bleed into the tissue. If the hematoma stabilizes, the provider may order the nurse to monitor and provide ice and pain control. If the hematoma is expanding or the patient's condition worsens, the physician will evacuate the hematoma and address the source of bleeding.