Postpartum hemorrhage PrepU

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 500 mL 750 mL 1000 mL 250 mL

Correct response: 1000 mL Explanation: Postpartum hemorrhage is defined as blood loss of 500 mL or more after a vaginal birth and 1000 ml or more after a cesarean birth.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "How much blood was on the two pads?" "Are you in any pain with your bleeding?" "When did you last void?"

Correct response: "How much blood was on the two pads?" Explanation: The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Initiate Ringer's lactate infusion. Assess the woman's vital signs. Call the woman's health care provider. Assess the woman's fundus.

Correct response: Assess the woman's fundus. Explanation: The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.

The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication? Urinary infection Excessive bleeding A ruptured bladder Bladder distention

Correct response: Bladder distention Explanation: The displacement of the uterus to one side is suggestive of bladder distention. The bladder should be emptied and then fundal massage instituted to encourage the uterus to contract and stop the excessive bleeding. If the uterus was in the midline, then this would be related solely to uterine bleeding. It's important to ensure the bladder is empty before starting the fundal massage to ensure the uterus will stay contracted. A urinary infection would be noted to cause burning on urination. A ruptured bladder would be indicative of hematuria as well as pelvic pain.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? The uterine placement is normal. The uterus is filling up with blood. The bladder is distended. There is an infection inside the uterus.

Correct response: The bladder is distended. Explanation: If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis? Assess for redness and warmth. Ask about increased pain with weight bearing. Ask if she has pain or tenderness in the lower extremities. Dorsiflex her right foot and ask if she has pain in her calf.

Correct response: Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A positive Homans sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for redness and warmth/ In addition, assess to see if she has increased pain when she ambulates or bears weight.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? Assess her blood pressure. Palpate her fundus. Have her turn to her left side. Assess her perineum.

Correct response: Palpate her fundus. Explanation: The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Warm and flushed skin Weak and rapid pulse Elevated blood pressure Decreased respiratory rate

Correct response: Weak and rapid pulse Explanation: Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is mostappropriate initially? massaging the fundus firmly performing bimanual compressions administering ergonovine notifying the primary care provider

Correct response: massaging the fundus firmly Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

A nurse decides to perform fundal massage based on findings that support which condition? uterine atony uterine prolapse uterine subinvolution uterine contraction

Correct response: uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally the nurse assists the woman with perineal care and applying a new perineal pad.

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? warm and flushed skin weak and rapid pulse elevated blood pressure decreased respiratory rate

Correct response: weak and rapid pulse Explanation: The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.