Postpartum Hemorrhage Practice Questions (Test #4, Fall 2020)

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for the past 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute

1 1. This output is below the accepted minimum for 8 hours. 2. This weight decrease following delivery is within normal limits. 3. A 2% drop in hematocrit is within normal limits. 4. This pulse rate is within normal limits. TEST-TAKING TIP: The nurse must divide the amount of urine output by the number of hours. The output in the scenario is equal to 25 mL/hr. This is well below the accepted output of 30 mL/ hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs. Postpartum clients often have slowed heartbeats.

A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal birth. The physician has prescribed IM prostaglandin-F2a. After administration of the medication, the nurse should observe the client for which of the following? 1.Tachycardia. 2.Hypotension. 3.Constipation. 4.Abdominal distention

1 Prostaglandin F2a promotes uterine contractions, thereby minimizing uterine atony and subsequent hemorrhage. Possible side effects include nausea, tachycardia, hypertension, and diarrhea. Abdominal distention is not associated with the use of prostaglandin F2a

A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which of the following information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit? 1.Firm fundus when gentle massage is used. 2.Evidence of bonding well with the neonate. 3.Labor that lasted 12 hours with a 1-hour second stage. 4.Temperature of 99°F (37.4°C) and pulse rate of 80 bpm.

1 The priority assessment is that the client has a firm fundus when gentle massage is used. This indicates that the client's fundus may be soft or "boggy" when it is not massaged. The receiving nurse should assess the client's fundus soon after admission and continue to monitor the client's fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal. The temperature and pulse are within normal limits.

The nurse delegates the care of a multiparous client who gave birth to a viable term neonate vaginally 30 hours ago and is preparing to be discharged to a licensed practical nurse (LPN). The nurse should instruct the LPN to notify the nurse if the client exhibits which of the following? 1.Pulse rate of 100 bpm. 2.Oral temperature of 99°F (36.8°C). 3.Excessive perspiration during the assessment. 4.Frequent voiding in large amounts.

1. During the first week postpartum, the client's pulse rate should be slow, with an average of 60 to 70 bpm. A pulse of 100 bpm warrants further investigation to rule out a possible infectious process or postpartum hemorrhage. An oral temperature of 99°F (36.8°C) is within normal limits. Excessive perspiration and frequent voiding in large amounts are caused by the normal diuresis that occurs as the body returns to its prepregnant state.

A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman? 1. Endometrial ischemia. 2. Postpartum hemorrhage. 3. Prolapsed uterus. 4. Vaginal hematoma.

2 1. Endometrial ischemia is not a complication of a succenturiate placenta. 2. The nurse should carefully monitor this client for signs of postpartum hemorrhage. 3. The client is not especially at high risk for a prolapsed uterus. 4. The client is not at high risk for a vaginal hematoma. TEST-TAKING TIP: Because a succenturiate placenta has extra lobe(s), the client is at high risk for hemorrhage from one or more of the lobes. The healthcare professional who performed the delivery may have noted one lobe but may not have realized that an additional lobe is still in utero.

A mother, G1 P1, who delivered a 2,800 gram baby vaginally 30 minutes earlier, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes later. She is receiving an intravenous with 20 units oxytocin added. The postpartum nurse questions why the oxytocin was added to the IV bag. Which of the following responses by the transferring nurse is most likely? 1. "The medication was added 10 minutes ago to prevent excess bleeding during her transfer." 2. "The medication was added immediately after the baby's birth to promote placental delivery." 3. "The medication was added after the placenta was delivered because of its rapid separation." 4. "The medication was added while she was pushing to speed up the baby's birth."

2 1. Patient transfer from labor and delivery to postpartum does not stimulate excess bleeding. It is unlikely that this is the rationale for the medication administration. 2. It is likely that the medication was added during the 3rd stage of labor to promote placental delivery. 3. Placental delivery usually occurs between 5 minutes and 30 minutes after the birth. This is an unlikely rationale for the medication administration. 4. The client's 2nd stage of labor lasted 45 minutes. That is a relatively short period of time for a primipara. As important, 20 units of oxytocin is an unsafe dosage to be administered before the fetus is birthed. TEST-TAKING TIP: Postpartum hemorrhage (PPH) is a leading cause of maternal death. One effective means of preventing PPH is active management of the 3 rd stage of labor. In other words, oxytocin is administered after the birth of the baby to promote uterine contraction and placental delivery. The oxytocin is usually added to the client's IV infusion and the infusion is continued until the fl uid is fully absorbed.

A mother, G6 P6006, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

2 1. This client is not especially at high risk for seizures. 2. The client should be monitored carefully for signs of postpartum hemorrhage. 3. This client is not especially at high risk for infection. 4. This client is not especially at high risk for thrombosis. TEST-TAKING TIP: An average size baby weighs 2,500 to 4,000 grams. The baby in the scenario is macrosomic. As a result, the mother's uterus has been stretched beyond its expected capacity. In addition, this client is a "grand multipara" or a woman who has delivered 5 or more babies. The client is at high risk for uterine atony, which could result in a postpartum hemorrhage.

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which of the following clients should the nurse assess first? 1.A multiparous client at 48 hours postpartum who is being discharged. 2.A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate. 3.A multiparous client at 24 hours postpartum whose infant is in the special care nursery. 4.A primiparous client at 48 hours after cesarean birth of a term neonate.

2 The primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the client's fundus, lochia, and vital signs, a determination about the stability of the client can be made. After this assessment, the nurse can provide care to the other clients, who are of lesser priority than the newly postpartum primiparous client.

A nurse is caring for the following four laboring patients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivered by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2 and 5 are correct. 1. Preterm labor clients are not especially at high risk for postpartum hemorrhage. 2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). 3. Cesarean section clients are not especially at high risk for PPH. 4. Postdates clients who deliver small babies are not especially at high risk for PPH. 5. Clients with a succenturiate placenta are at high risk for PPH. TEST-TAKING TIP: The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). These clients must be monitored carefully for postpartum hemorrhage.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation? 1.Her bleeding needs to be reported to the physician immediately. 2.The increased lochia occurs from lochia pooling in the vaginal vault. 3.The increase in lochia may be an early sign of postpartum hemorrhage. 4.This increase in lochia usually indicates retained placental fragments"

2. Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.

Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration in comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3 1. This is an important nursing diagnosis, but it is not the priority diagnosis. 2. This is an important nursing diagnosis, but it is not the priority diagnosis. 3. Fluid volume deficit related to blood loss is the priority nursing diagnosis. 4. This is an important nursing diagnosis, but it is not the priority diagnosis. TEST-TAKING TIP: It is likely that most clients will have multiple nursing diagnoses. The nurse must then determine which is (are) the priority diagnosis(ses). It is essential that the nurse remember Maslow's hierarchy of needs. Although psychosocial needs are very important, the physiological needs, especially those related to the respiratory and the cardiovascular systems, must take precedence.

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider about: 1.Bleeding that becomes lighter each day 2.Clots the size of golf balls 3.Saturating a pad in an hour 4.Lochia that lasts longer than 1 week

3 A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum

A client has experienced a postpartum hemorrhage. The primary health care provider verbally ordered carboprost tromethamine (Hemabate) 0.25 mg IM stat at the time of the hemorrhage and this was given by the nurse. The primary health care provider put a prescription into the electronic medical record for 0.25 mg carboprost tromethamine IV stat. When seeing the prescription, how should the nurse administering the carboprost tromethamine respond? 1.Ask the charge nurse to have a discussion with the primary health care provider about the prescription. 2.Initiate an incident report. 3.Call the primary health care provider, discuss the prescription, and request revision if heard correctly. 4.Wait until the primary health care provider returns to the unit and discuss the situation in person.

3 In emergency situations, verbal prescriptions should be entered into the electronic medical record or chart and signed immediately after the emergency. The nurse taking this prescription and giving the medication needs to call the primary health care provider, explain the prescription and that the medication was administered per the verbal prescription, and request that the primary health care provider write the correct prescription. If the nurse misunderstood the prescription and gave the medication by the wrong route, an incident report will need to be initiated. The charge nurse would become involved if an error has occurred, an incident report is needed, or there is difficulty between the nurse and primary health care provider that cannot be remediated. Rectifying this prescription is the responsibility of the implementing nurse. Waiting until the primary health care provider comes back to the hospital unit may not occur quickly enough to safely care for the client.

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

4 1. The nurse would not expect to see engorgement. 2. The nurse would not expect to see mastitis. 3. The nurse would not expect to see a blocked milk duct. 4. The nurse would expect that the woman would have a low milk supply. TEST-TAKING TIP: The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies. Women with retained placental fragments are also at high risk for postpartum hemorrhage and intrauterine infection.

A multiparous client visits the urgent care center 5 days after a vaginal birth, experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, "Why am I continuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following? 1.Uterine atony. 2.Cervical lacerations. 3.Vaginal lacerations. 4.Retained placental fragments.

4 The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be scheduled for a dilatation and curettage to remove remaining placental fragments. Uterine atony, cervical lacerations, and vaginal lacerations are commonly associated with early, not late, postpartum hemorrhage.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following? 1.Trauma during labor and birth. 2.Moderate fundal massage after birth. 3.Lengthy and prolonged second stage of labor. 4.Overdistention of the uterus from hydramnios."

4 The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that she had a long labor.