Ch 21 Postpartum Complications, Ch 18 Maternal Physiologic Changes
Postpartum hemorrhage (PPH) The uterine walls are overstretched in multifetal gestation, so it contracts poorly after birth. This may cause uterine atony leading to postpartum hemorrhage (PPH). Multifetal gestation does not cause vaginal hematomas, von Willebrand disease (vWD), or abnormal limb development of the fetus. Vaginal hematomas occur more commonly in association with a forceps-assisted birth. vWD is a type of hemophilia, which is a hereditary bleeding disorder. Abnormal development of fetal limbs is usually a complication associated with teratogenic drugs.
After reviewing a patient's medical reports, the nurse finds that the patient has multifetal gestation. What is the most likely complication associated with this? 1 Vaginal hematomas 2 von Willebrand disease (vWD) 3 Postpartum hemorrhage (PPH) 4 Abnormal development of limbs
The fundus descends gradually from the time of childbirth and returns to its normal nonpregnant state. By the sixth day after childbirth, it can be located halfway between the umbilicus and the symphysis pubis. The fundus rises to approximately 1 cm above the umbilicus within 12 hours of childbirth. Within 24 hours, the fundus descends 1 to 2 cm, and the size of the uterus is the same as during 20 weeks' gestation. By the sixth week, the uterus returns to its normal, nonpregnant state.
While examining the postpartum patient, the nurse finds that her fundus is located halfway between the umbilicus and the symphysis pubis. When would the nurse suspect was about the time of the patient's delivery? 1 6 days ago 2 12 hours ago 3 24 hours ago 4 6 weeks ago
Puerperium The time interval between the birth of the newborn and the return of the patient's reproductive organs to their normal nonpregnant state is termed puerperium, or the fourth trimester of pregnancy. This period usually lasts for 6 weeks. Lochia refers to uterine discharge after birth. Involution refers to the return of the uterus to its nonpregnant state after birth. Subinvolution refers to the failure of the uterus to return to its nonpregnant state after childbirth.
Which term is used to describe the period between childbirth and the reversal of the mother's uterus into its nonpregnant state? 1 Lochia 2 Involution 3 Puerperium 4 Subinvolution
Check her perineal pad The patient is exhibiting increasing anxiety, which can signal the presence of postpartum hemorrhage. Risk factors for postpartum hemorrhage include a large fetus, prolonged labor, and a forceps-assisted birth. Because vital signs change late, the fastest way to see the amount of current hemorrhage is to check the perineal pad. The fundus would be massaged and additional nursing and medical interventions would be instituted.
A 28-year-old multipara delivered a 9 pound, 3 ounce baby girl an hour ago after a 22-hour labor with a forceps-assisted birth. As the patient is holding her daughter, she keeps shifting position and is becoming increasingly irritable and annoyed with everyone in the room. What action should the nurse initially take? 1 Massage the fundus. 2 Check her perineal pad. 3 Assess her vital signs. 4 Check the tone of her fundus
Blood pressure More than 100 mL of blood is lost during a cesarean section. Therefore the nurse should continuously monitor the blood pressure of the patient to check the extent of hypovolemia. The platelet count would be reduced because of blood loss. However, its determination would not help to know the extent of the blood loss. The blood gas levels should be checked to detect metabolic or respiratory disorders, which change the pH of the blood. The respiratory rate would be increased because of the blood loss. However, these values would not help determine whether the patient was in hypovolemic shock.
A deceased fetus has been removed from a patient through cesarean section. What critical assessment should the nurse continuously monitor in the patient? 1 Blood gases 2 Platelet count 3 Blood pressure 4 Respiratory rate
Perform a Hysterectomy Placenta accreta is an obstetric complication in which the placenta adheres to and penetrates the myometrium. The patient with placenta accreta is at risk of hemorrhage during childbirth. If bleeding is not stopped after the administration of medication to the patient, a hysterectomy must be performed to prevent further complications. Replacement of blood components is not useful because the patient has uncontrolled bleeding. Massaging the uterus and applying traction to the umbilical cord is helpful to expel the placenta but is not useful when the placenta is adhered to the uterus.
A patient diagnosed with placenta accreta has uncontrolled bleeding, despite medications. What is the best choice for treatment in this situation? 1 Massage the uterus. 2 Perform a hysterectomy. 3 Replace blood components as needed. 4 Apply traction on the umbilical cord.
Stress of childbirth in the patient Postpartum-onset preeclampsia Leakage of the cerebrospinal fluid Persistent headache in postpartum patients need to be evaluated further. However, the stress and physical fatigue of childbirth may cause the patient to experience headaches. Postpartum-onset preeclampsia, characterized by high blood pressure and the presence of proteins in the urine, may also cause headaches. Epidural or spinal anesthesia involves the placement of the needle into the spinal space. This may lead to leakage of cerebrospinal fluid into the extradural space, resulting in a headache. Orthostatic hypotension may cause dizziness, but it does not cause headache. The presence of varices and hemorrhoids may cause discomfort and pain, but these do not cause headache.
A postpartum patient complains of a headache. What could be the reasons for the headache in the patient? Select all that apply. 1 Orthostatic hypotension 2 Stress of childbirth in the patient 3 Postpartum-onset preeclampsia 4 Leakage of the cerebrospinal fluid 5 Presence of varices and hemorrhoid
Infuse fresh frozen plasma When a postpartum patient has excessive bleeding from hemorrhagic shock, an I.V. infusion of crystalloid solution is administered. If the platelet count is not restored even after the crystalloid I.V. infusion process, fresh frozen plasma must be infused. Fresh frozen plasma contains all of the coagulation factors, and it helps restore platelet counts. Packed red blood cells are administered if the patient has active bleeding despite the initial crystalloid administration. Increasing the dose or volume of crystalloid solution will not increase the levels of clotting factors and platelets. Supplementary oxygenation is given to compensate the reduced tissue perfusion when the patient has hypovolemic shock. Supplementary oxygenation does not increase the levels of clotting factors and platelets.
A postpartum patient experiencing hemorrhagic shock has been administered an I.V. infusion of crystalloid solution. Upon reviewing the patient's laboratory reports, the nurse finds that platelet count and clotting factor levels have not improved. What is the best treatment option in this situation? 1 Infuse fresh frozen plasma. 2 Provide supplemental oxygenation. 3 Administer packed red blood cells. 4 Increase the dose of crystalloid solution.
Platelet count Fibrinogen level Proaccelerin level Red blood cell count DIC is the result of an imbalance between the clotting and fibrinolytic systems. DIC is caused by diffused clots in the microcirculation that block the small vessels. DIC consumes large amounts of platelets, prothrombin, fibrinogen, and factors V and VII. This causes a decrease in the platelets, fibrinogen, antihemophiliac factor, prothrombin, and proaccelerin. DIC can lead to significant bleeding, which may cause reduction of red blood cells. The levels of white blood cells are not affected in DIC, nor do they interfere with the clotting process.
After reviewing the laboratory reports, the nurse concludes that a patient has disseminated intravascular coagulation (DIC). Which findings led the nurse to conclude this? Select all that apply. A decrease in: 1 Platelet count 2 Fibrinogen level 3 Proaccelerin level 4 Red blood cell count 5 White blood cell count
desmopressin Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products, such as factor VIII and vWf, are an acceptable option for this patient. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice. Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Although the administration of this prostaglandin is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the patient who presents with a bleeding disorder.
Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. Von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the woman with von Willebrand disease who experiences a postpartum hemorrhage is: 1 cryoprecipitate. 2 factor VIII and vWf. 3 desmopressin. 4 hemabate
"Wash your vagina with a chlorine solution twice a day." Patients with genital fistulas often experience depression because of a foul odor from the vagina and loss of sexual intimacy with their partners. Maintenance of hygiene helps to reduce the odor and vaginal irritation. Therefore the nurse should suggest that the patient wash her vagina with a chlorine solution and commercial deodorizing douches. The nurse should suggest that the patient wash her vagina with warm water and mild soap, rather than cold water, to provide comfort. Using scented diaphragms may not help prevent irritation and foul odor in the vagina. The patient may feel rejected and depressed if the nurse gives judgmental statements and encourages the patient to avoid having sex with her partner.
The nurse is assessing a postpartum patient with genital fistulas. The patient tells the nurse, "I feel embarrassed, because my vagina has a bad odor. My partner is unwilling to maintain sexual intimacy with me because of it." What should the nurse suggest in this situation? 1 "Use scented diaphragms while having sex." 2 "Wash your vagina with cold water before having sex." 3 "Wash your vagina with a chlorine solution twice a day." 4 "Avoid having sex until your fistulas are surgically removed."
To promote hemostasis To compress blood vessels To increase the uterine contractions (UCs) Oxytocin (Pitocin) is a hormone that is secreted in postpartum patients. Oxytocin causes smooth muscle contractions and increases the UCs, which, in turn, compresses the blood vessels and promotes hemostasis. Lochia alba is a postbirth uterine discharge, and oxytocin has no effect on lochia alba. The afterpains are intensified as a result of the oxytocin; there is a direct effect of oxytocin on smooth muscle contractions. The more intense the contractions are during labor, the greater are the afterpains. Subinvolution is the failure of the uterus to return to its normal shape after delivery, and it cannot be treated by oxytocin.
The nurse is caring for a postpartum patient. Within 1 to 2 hours of delivery, the primary health care provider (PHP) prescribes intravenous (I.V.) oxytocin (Pitocin) for the patient. What are the most probable reasons for this prescription? Select all that apply. 1 To treat subinvolution 2 To decrease afterpains 3 To decrease lochia alba 4 To promote hemostasis 5 To compress blood vessels 6 To increase the uterine contractions (UCs)
Superficial venous thrombosis. Deep vein thrombosis. Pulmonary embolism An AFE occurs during the intrapartum period when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis, the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs. DIC is an imbalance between the body's clotting and fibrinolytic systems. It's a pathologic form of clotting that consumes large amounts of clotting factors.
Thromboembolic conditions that are of concern during the postpartum period include: Select all that apply. 1 Amniotic fluid embolism (AFE). 2 Superficial venous thrombosis. 3 Deep vein thrombosis. 4 Pulmonary embolism. 5 Disseminate intravascular coagulation (DIC)
hematoma formation Bladder distention would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse would suspect: 1 bladder distention. 2 uterine atony. 3 constipation. 4 hematoma formation
Anesthesia Anesthesia blocks the neurologic impulses that stimulate uterine contractions (UCs). This causes uterine atony and can lead to PPH. Chorioamnionitis is a serious condition in which the fetal membranes are infected and is associated with other signs, such as fever. Coagulopathy is a clotting disorder that results from protein defects in the plasma that interrupt the coagulation cascade and cause blood coagulation. Placenta previa is an obstetric complication in which the placenta penetrates partially in the lower uterine segment. This is a common complication in pregnant women who smoke and consume cocaine.
Upon assessment the nurse finds that a patient who had a cesarean delivery is at risk of postpartum hemorrhage (PPH). What would be the most likely cause of PPH in this patient? 1 Anesthesia 2 Coagulopathy 3 Placenta previa 4 Chorioamnionitis
The patient may be expressing mature milk In postpartum women, the colostrum transforms to mature milk within approximately 72 to 96 hours after birth. This mature milk is slightly bluish in color. Thus, based on the finding, the nurse would infer that the patient is expressing mature milk. There are no secretions from the nipples in cases of breast abscess. Colostrum is clear, yellow fluid, which is commonly secreted immediately after birth. Fibrocystic changes in the breast are characterized by nodular lumps in the breast, which are always palpable in the same location.
What does the nurse infer about the patient's condition from the finding of slightly bluish-colored milk expressed from the breasts of a postnatal patient? 1 The patient may have a breast abscess. 2 The patient may be expressing colostrum. 3 The patient may be expressing mature milk. 4 The patient may have fibrocystic changes in the breast
Rugae reappear within 3 to 4 weeks Rugae appear within 3 weeks, but they are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.
Which description of postpartum restoration or healing times is accurate? 1 The cervix shortens, becomes firm, and returns to form within a month postpartum. 2 Rugae reappear within 3 to 4 weeks. 3 Most episiotomies heal within a week. 4 Hemorrhoids usually decrease in size within 2 weeks of childbirth.
Partial separation of the placenta The color and quality of the blood loss that the patient is experiencing after delivery (from the childbirth and the separation of the placenta) indicate that the patient has postpartum hemorrhage. The presence of spurts of clotted blood indicates that the patient has partial placental separation. Disseminated intravascular coagulation (DIC), also known as coagulopathy, is characterized by excessive bleeding caused by a lack of clotting factor. Bright red blood indicates that the bleeding is coming from deep lacerations of the birth canal. Dark red blood is indicative of bleeding from superficial lacerations of the birth canal.
While caring for a postpartum patient, the nurse finds that the patient has spurts of blood with clots. What does the nurse infer about the patient's clinical condition from this sign? 1 Partial separation of the placenta 2 Disseminated intravascular coagulation (DIC) 3 Bleeding from deep lacerations of the birth canal 4 Bleeding from superficial lacerations of the birth canal
more noticeable in births in which the uterus was overdistended Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large infant or multiple infants overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Breastfeeding intensifies afterbirth pain because it stimulates contractions
With regard to afterbirth pains, nurses should be aware that these pains are: 1 caused by mild, continual contractions for the duration of the postpartum period. 2 more common in first-time mothers. 3 more noticeable in births in which the uterus was overdistended. 4 alleviated somewhat when the mother breastfeeds.
