OB - Chapter 22
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage based on the knowledge that:
A) These measurements may not change until after the blood loss is large B) The body's compensatory mechanisms activate and prevent any changes C) They relate more to change in condition than to the amount of blood lost D) Maternal anxiety adversely affects these vital signs Ans: A Feedback: The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 mL of blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus and on perineal pads, mattresses, and the floor.
Ans: B Feedback: The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract and retract after birth. The uterus must remain contracted after birth to control bleeding from the placental site. Labor augmentation is a risk factor for postpartum hemorrhage. Lacerations of the birth canal and uterine inversion may cause postpartum hemorrhage, but these are not the most common cause.
A group of students are reviewing the causes of postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as the most common cause? A) Labor augmentation B) Uterine atony C) Cervical or vaginal lacerations D) Uterine inversion
Ans: D Feedback: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the following? A) An inverted nipple on the affected breast B) No breast milk in the affected breast C) An ecchymotic area on the affected breast D) Hardening of an area in the affected breast
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?
A) "I just feel so overwhelmed and tired." B) "I'm feeling so guilty and worthless lately." C) "It's strange, one minute I'm happy, the next I'm sad." D) "I keep hearing voices telling me to take my baby to the river." Ans: B Feedback: Indicators for postpartum depression include feelings related to restlessness, worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and loss of libido. Thus, the statement by the mother about feeling guilty and worthless suggest postpartum depression. The statements about being overwhelmed and fatigued and changing moods suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis.
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?
A) "I need to call my doctor if my temperature goes above 100.4°F" B) "When I put on a new pad, I'll start at the back and go forward." C) "If I have chills or my discharge has a strange odor, I'll call my doctor." D) "I'll point the spray of the peribottle so the water flows front to back." Ans: B Feedback: The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-to-back motion. Notifying the health care provider of a temperature above 100.4° F, aiming the peribottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching.
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman states which of the following?
A) "I will use a soft toothbrush to brush my teeth." B) "I can take ibuprofen if I have any pain." C) "I need to avoid drinking any alcohol." D) "I will call my health care provider if my stools are black and tarry." Ans: B Feedback: Individuals receiving anticoagulant therapy need to avoid use of any over-the-counter products containing aspirin or aspirin-like derivatives such as NSAIDs (ibuprofen) to reduce the risk for bleeding. Using a soft toothbrush and avoiding alcohol are appropriate measures to reduce the risk for bleeding. Black, tarry stools should be reported to the health care provider.
A postpartum woman is ordered to receive oxytocin to stimulate the uterus to contract. Which of the following would be most important for the nurse to do?
A) Administer the drug as an IV bolus injection. B) Give as a vaginal or rectal suppository. C) Piggyback the IV infusion into a primary line. D) Withhold the drug if the woman is hypertensive. Ans: C Feedback: When giving oxytocin, it should be diluted in a liter of IV solution and the infusion set up to be piggy-backed into a primary line to ensure that the medication can be discontinued readily if hyperstimulation or adverse effects occur. It should never be given as an IV bolus injection. Methylergonovine is not given if the woman is hypertensive. Dinoprostone is available as a vaginal or rectal suppository.
Ans: B Feedback: The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract and retract after birth. The uterus must remain contracted after birth to control bleeding from the placental site. Labor augmentation is a risk factor for postpartum hemorrhage. Lacerations of the birth canal and uterine inversion may cause postpartum hemorrhage, but these are not the most common cause.
A) Administering broad-spectrum antibiotics B) Inspecting the placenta after delivery for intactness C) Manually removing the placenta at delivery D) Applying pressure to the umbilical cord to remove the placenta Ans: B Feedback: After birth, a thorough inspection of the placenta is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
A nurse suspects that a postpartum client is experiencing postpartum psychosis. Which of the following would most likely lead the nurse to suspect this condition?
A) Delirium B) Feelings of anxiety C) Sadness D) Insomnia Ans: A Feedback: Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.
A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action:
A) Determines that the procedure is effective B) Helps support the lower uterine segment C) Aids in expressing accumulated clots D) Prevents uterine muscle fatigue Ans: B Feedback: The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The hand, usually the dominant hand that is placed on the fundus, helps to determine uterine firmness (and thus the effectiveness of the massage). Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the uterus leads to muscle fatigue.
Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which of the following would the nurse expect to assess? (Select all that apply.)
A) Diaphoresis B) Tachycardia C) Oliguria D) Cool extremities E) Confusion Ans: A, D Feedback: Signs and symptoms of mild shock include diaphoresis, increased capillary refill, cool extremities, and maternal anxiety. Tachycardia and oliguria suggest moderate shock. Confusion suggests severe shock
A multipara client develops thrombophlebitis after delivery. Which of the following would alert the nurse to the need for immediate intervention?
A) Dyspnea, diaphoresis, hypotension, and chest pain B) Dyspnea, bradycardia, hypertension, and confusion C) Weakness, anorexia, change in level of consciousness, and coma D) Pallor, tachycardia, seizures, and jaundice Ans: A Feedback: Sudden unexplained shortness of breath and complaints of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.
A group of nursing students are reviewing information about mastitis and its causes. The students demonstrate understanding of the information when they identify which of the following as the most common cause?
A) E. coli B) S. aureus C) Proteus D) Klebsiella Ans: B Feedback: The most common infectious organism that causes mastitis is S. aureus, which comes from the breast-feeding infant's mouth or throat. E. coli is another, less common cause. E.coli, Proteus, and Klebsiella are common causes of urinary tract infections.
A postpartum woman is diagnosed with metritis. The nurse interprets this as an infection involving which of the following? (Select all that apply.)
A) Endometrium B) Decidua C) Myometrium D) Broad ligament E) Ovaries F) Fallopian tubes Ans: A, B, C Feedback: Metritis is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus. Extension of metritis can result in parametritis, which involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic thrombophlebitis,
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which of the following?
A) Hematoma B) Laceration C) Bladder distention D) Uterine atony Ans: A Feedback: The woman most likely has a hematoma based on the findings: firm uterus with bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area; severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony would be noted by an uncontracted uterus.
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which of the following in the mother and the newborn?
A) Infection B) Hemorrhage C) Trauma D) Hypovolemia Ans: A Feedback: Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid so bacteria can ascend.
A nurse is assessing a postpartum woman. Which finding would cause the nurse to be most concerned?
A) Leg pain on ambulation with mild ankle edema B) Calf pain with dorsiflexion of the foot. C) Perineal pain with swelling along the episiotomy D) Sharp stabbing chest pain with shortness of breath Ans: D Feedback: Sharp stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent.
A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels "lousy." Which of the following findings would lead the nurse to suspect metritis? (Select all that apply.)
A) Lower abdominal tenderness B) Urgency C) Flank pain D) Breast tenderness E) Anorexia Ans: A, E Feedback: Manifestations of metritis include lower abdominal tenderness or pain on one or both sides, elevated temperature, foul-smelling lochia, anorexia, nausea, fatigue and lethargy, leukocytosis and elevated sedimentation rate. Urgency and flank pain would suggest a urinary tract infection. Breast tenderness may be related to engorgement or suggest mastitis.
A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which of the following?
A) Nonpalpable fundus B) Moderate lochia serosa C) Bruising on arms and legs D) Fever Ans: B Feedback: Subinvolution is usually identified at the woman's postpartum examination 4 to 6 weeks after birth. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would suggest a coagulopathy. Fever would suggest an infection.
A woman experiencing postpartum hemorrhage is ordered to receive a uterotonic agent. Which of the following would the nurse least expect to administer?
A) Oxytocin B) Methylergonovine C) Carboprost D) Terbutaline Ans: D Feedback: Terbutaline is a tocolytic agent used to halt preterm labor. It would not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.
Which of the following would be most appropriate when massaging a woman's fundus?
A) Place the hands on the sides of the abdomen to grasp the uterus. B) Use an up-and-down motion to massage the uterus. C) Wait until the uterus is firm to express clots. D) Continue massaging the uterus for at least 5 minutes. Ans: C Feedback: The uterus must be firm before attempts to express clots are made because application of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions are used for massage. There is no specified amount of time for fundal massage. Uterine tissue responds quickly to touch, so it is important not to overmassage the fundus.
A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which of the following would the nurse include as the most cost-effective method for prevention?
A) Prophylactic heparin administration B) Compression stocking C) Early ambulation D) Warm compresses Ans: C Feedback: Although compression stockings and prophylactic heparin administration may be appropriate, the most cost-effective preventive method is early ambulation. It is also the easiest method. Warm compresses are used to treat superficial venous thrombosis.
A group of students are reviewing risk factors associated with postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as associated with uterine tone? (Select all that apply.)
A) Rapid labor B) Retained blood clots C) Hydramnios D) Operative birth E) Fetal malposition Ans: A, C Feedback: Risk factors associated with uterine tone include hydramnios, rapid or prolonged labor, oxytocin use, maternal fever, or prolonged rupture of membranes. Retained blood clots are a risk factor associated with tissue retained in the uterus. Fetal malposition and operative birth are risk factors associated with trauma of the genital tract.
The nurse is assessing a woman with abruption placentae who has just given birth. The nurse would be alert for which of the following?
A) Severe uterine pain B) Board-like abdomen C) Appearance of petechiae D) Inversion of the uterus Ans: C Feedback: A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with abruptio placentae.
The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which of the following would the nurse most likely include in this teaching plan? (Select all that apply.)
A) Taking the prescribed antibiotic until it is finished B) Checking temperature once a week C) Washing hands before and after perineal care D) Handling perineal pads by the edges E) Directing peribottle to flow from back to front Ans: A, C, D Feedback: Teaching should address taking the prescribed antibiotic until finished to ensure complete eradication of the infection; checking temperature daily and notifying the practitioner if it is above 100.4° F; washing hands thoroughly before and after eating, using the bathroom, touching the perineal area, or providing newborn care; handling perineal pads by the edges and avoiding touching the inner aspect of the pad that is against the body; and directing peribottle so that it flows from front to back.
Ans: D Feedback: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.
As part of an inservice program, a nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse correctly identifies this as postpartum: A) Depression B) Psychosis C) Bipolar disorder D) Blues
Ans: C Feedback: The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following? A) Retained placental fragments B) Hypertension C) Thrombophlebitis D) Uterine subinvolution