chapter 22 Postpartum complications
A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?
uterine atony Explanation: Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.
A postpartum woman is being treated for hemorrhage and is to receive a blood transfusion. The nurse understands that this treatment is being instituted based on which amount of estimated blood loss?
1,500 ml Explanation: Once estimates of blood loss reach 1,500 ml to 2000 ml, transfusion of blood products should be instituted immediately.
What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?
Activated partial thromboplastin time Explanation: The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.
Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Explanation: Postpartum women who void in small amounts may be experiencing bladder overflow from retention.
The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain?
Semi-Fowler Explantion: A semi-Fowler position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would not accomplish this goal and could result in the infection spreading to other parts of the body.
The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed?
When I am sleeping or lying in bed, I should lie flat on my back." Explanation: With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions.
Which measurement best describes postpartum hemorrhage?
blood loss of 1,000 ml, occurring at least 24 hours after birth Explanation: Postpartum hemorrhage involves blood loss in excess of 1,000 mL within the first 24 hours of delivery.
A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage?
by frequently assessing uterine involution Explanation: The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.
A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem?
multiparity Explanation: Risk factors for postpartum hemorrhage due to uterine atony include many factors, including multiparity. Placenta accreta is associated with placental issues, preeclampsia is seen in disruption of maternal clotting factors, and fetal demise can cause a disruption in maternal clotting factors, but not uterine atony.
Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client?
oxytocin agent Explanation: The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.
Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client?
temperature of 38°C (100.4°F) or higher after the first 24 hours after birth Explanation: Postpartum infection is defined as a fever of 38°C or 100.4°F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours
After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?
"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.
A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear within which time frame after birth?
3 months Explanation: Postpartum psychosis generally surfaces within 3 months of giving birth. Reference:
A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding?
Large uterus with painless dark red blood mixed with clots Explanation: The presence of a large uterus with painless dark red blood mixed with clots indicates retained placental fragments in the uterus. This cause of hemorrhage can be prevented by carefully inspecting the placenta for intactness. A firm uterus with a trickle or steady stream of bright red blood in the perineum indicates bleeding from trauma. A soft and boggy uterus that deviates from the midline indicates a full bladder, interfering with uterine involution.
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?
Pad count Explanation: The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.
A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action?
Report the finding promptly to the primary care provider. Explanation: This client's presentation is consistent with a hematoma, which indicates a hemorrhage and which must be treated promptly. Reporting this change in status is priority over hot/cold treatments. This is not an expected finding.
The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?
You need to avoid medications which contain acetylsalicylic acid." Explanation: The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.
The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?
deep venous thrombosis Explanation: Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity.
An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?
length of labor Explanation: The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk.
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?
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.
A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.
Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. Explanation: A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.
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?
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.
It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?
Client's temperature remains below 100.4°F (38.8°C) orally. Explanation: As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature.
A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client?
Encourage an oral intake of 2 to 3 liters per day. Explanation: Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 ml/hr. The other three actions are important but not the highest priority for this client.
A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client? You Selected:
Encourage an oral intake of 2 to 3 liters per day. Explanation: Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 ml/hr. The other three actions are important but not the highest priority for this client.
Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution?
Her uterus is at the level of the umbilicus. Explanation: A uterus involutes at a rate of one finger width daily. On the third postpartum day, it is normally three finger widths below the umbilicus
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?
Symptoms include fever, chills, malaise, and localized breast tenderness. Explanation: Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
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.
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?
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.
A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug?
cardiovascular disease Explanation: Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident (stroke) in women at risk with preexisting conditions. Low blood pressure, respiratory problems, or mild fever are not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage
A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
Endometritis Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.3°C], possibly as high as 104°F [40° C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absen
A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question?
Take an oral contraceptive pill daily. Explanation: When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptive pills, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT.
A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?
administration of platelet transfusions as prescribed Explanation: When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?
applying ice Explanation: Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?
drop in estrogen and progesterone levels after birth Explanation: Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.
The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client
administrating a selective serotonin reuptake inhibitor Explanation: Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother.