Unit 4 - Care of Family Ch. 16

9. A nurse is caring for a patient who has excessive blood loss post-delivery from uterine atony. The perinatal nurse notifies the health-care provider while another nurse performs uterine massage. Which medication does the nurse anticipate to be given as the priority? A. Carboprost (Hemabate) B. Ergonovine (Ergotrate) C. Methylergonovine (Methergine) D. Oxytocin (Pitocin)

ANS: D If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large-bore needle and administers oxytocic drugs, starting with oxytocin. The other options are all useful in controlling postpartum hemorrhage, but oxytocin should be administered first.

38. A woman is being treated for endometritis after a cesarean birth. To prevent a possible complication, what action by the nurse is best? A. Encourage the woman to empty her bladder every 4 hours. B. Instruct the woman to monitor her temperature at home. C. Prepare the woman to have cultures of her lochia taken. D. Teach her to splint her abdominal incision when coughing.

ANS: D One possible complication of endometritis is dehiscence of incisions, such as from a cesarean birth or an episiotomy. Teaching the woman to firmly splint the incision when she coughs will add support and decrease the likelihood of this occurring. Taking one's temperature and collecting cultures do not prevent a complication; these are used for monitoring and diagnosing. Emptying the bladder is unrelated.

11. A postpartum patient is ready for discharge from the hospital with her baby. She describes having some "sad feelings" after her last baby. The perinatal nurse explains that she should seek help in which situation? A. After 2 weeks of continuous sad feelings B. After 3 weeks of continuous sad feelings C. After 1 month of continuous sad feelings D. After 6 weeks of continuous sad feelings

ANS: A Cases of postpartum blues are common. Fifty to 80% of all postpartum women experience some degree of postpartum blues within the first 2 weeks after childbirth. These are usually self-limiting, last several days, and often peak by the end of the first week. After 2 weeks, the woman should seek assistance and have further screening for depression.

3. The perinatal nurse recognizes that which common organism is responsible for postpartum infection manifesting with scant, odorless lochia? A. Beta-hemolytic streptococcus B. Chlamydia trachomatis C. Escherichia coli D. Treponema pallidum

ANS: A Endometrial infections caused by beta-hemolytic streptococcus are characterized by scant, odorless lochia.

18. A perinatal clinic nurse develops concerns about a postpartum woman and her infant at the first well-baby checkup. The nurse has assessed several risk factors for depression. Which action by the nurse is most appropriate? A. Administer the Edinburgh Postnatal Depression Scale. B. Contact Children and Family Services or Child Protective Services. C. Notify the Visiting Nurses Association and request a home visit. D. Provide information and teaching on the postpartum blues.

ANS: A If the nurse believes that the new mother is demonstrating signs and symptoms of postpartum depression, several depression screening tools are available, including the Edinburgh Postnatal Depression Scale, Postpartum Depression Predictors Inventory, Center for Epidemiological Studies—Depression, and Beck Depression Inventory II. Because they are highly predictive, these scales are valuable tools that can be combined with the informal interview during a routine post-birth checkup.

20. A nurse is assessing a woman who had a postpartum hemorrhage treated with fundal massage and oxytocin (Pitocin). Which assessment finding would require the nurse to intervene immediately? A. Mean arterial pressure of 58 mm Hg B. Pain of 4 on a pain scale of 1 (least amount) to 10 (most amount) 1 hour after the pain medication was administered C. Used perineal pad weight of +80 g in 2 hours D. Urinary bladder nondistended, no urge to void

ANS: A One of the first signs of hypovolemic shock is a decrease in mean arterial pressure (MAP). MAP should be at least 60 mm Hg. To determine MAP, add the systolic pressure to the doubled diastolic pressure, and divide that sum by 3. The pain level may or may not be improved after medication; the nurse needs further information to determine if the medication has been effective. A perineal pad can hold 50 to 80 mL; 1 g of weight equals 1 mL of fluid, so this pad holds 80 mL. An 80-mL blood loss in 2 hours is not alarming. A distended bladder can contribute to uterine atony (and bleeding), so a nondistended bladder and no patient urge to void does not warrant intervention.

7. The perinatal nurse routinely screens pregnant women for postpartum depression. Which woman does the nurse screen as the priority? A. Adolescent B. Age 35 years or older C. Ambivalent at first visit D. First pregnancy

ANS: A Recognized risk factors for postpartum depression include an undesired/unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness. Ambivalence is not unusual, especially in the first trimester. First pregnancy is not a risk factor.

27. A postpartum woman who had a cesarean birth complains of warmth and pain in one of her calves. Which assessment should the nurse perform as the priority? A. Bilateral calf circumference B. Homans' sign on both legs C. Lung sounds and oxygen saturation D. Pedal and popliteal pulses

ANS: A Several clinical manifestations exist for DVT, including pain, calf tenderness, and leg swelling. The nurse can also assess warmth, redness, and possibly a palpable cord. The most accurate assessment is to measure and compare calf circumference; a 2-cm or greater increase on the painful side is an objective finding for DVT. Homans' sign is an assessment for DVT but may be inaccurate in as many as 50% of patients with DVT. Pulses may or may not be decreased, and the popliteal pulse is difficult to find in most patients. Because the patient did not complain of respiratory problems, listening to lung sounds and obtaining a pulse oximeter measurement is not the priority.

31. A woman with postpartum depression is being treated with a selective serotonin reuptake inhibitor (SSRI). What statement by the patient requires further action by the nurse? A. "Adding St. John's wort has really helped my depression." B. "I have started using aromatherapy and it helps a little." C. "Increasing my calcium intake seems to have a positive effect." D. "My baby seemed sleepier so I stopped breastfeeding him."

ANS: A St. John's wort has been used to treat depression but cannot be taken with SSRIs because of the possibility of the patient developing a serious condition known as serotonin syndrome. This herb can also increase the side effects associated with SSRIs. The other statements are appropriate.

14. A postpartum woman has a deep vein thrombosis. The patient states, "I feel anxious and have some pain in my chest." The patient's respiratory rate is 28 breaths per minute. After calling for help, which action by the perinatal nurse takes priority? A. Administer oxygen. B. Document the findings. C. Take a full set of vital signs. D. Prepare to give pain medication.

ANS: A The presence of dyspnea and tachypnea may signal pulmonary embolism, and the nurse should summon help immediately to deal with this condition. After that, administer oxygen, raise the head of the bed, assess vital signs, or begin CPR immediately if needed. Documentation is only correct as the priority action when the findings are normal. Pain medication is a lower priority.

12. Approximately 8 hours ago, a woman gave birth after 2.5 hours of pushing. She required an episiotomy and an assisted birth (forceps). The perinatal nurse assesses a slight bulge in the perineum and the presence of ecchymosis to the right of the episiotomy. The area feels "full" and is approximately 4 cm in diameter. The patient describes this area as "tender." What intervention does the nurse anticipate for this situation? A. Application of ice B. Exploratory surgery C. Incision and drainage D. Sitz bath every 12 hours

ANS: A This patient has a perineal hematoma. If the hematoma is less than 3 to 5 cm in diameter, the physician usually orders palliative treatments, such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 cm may require incision and drainage with the possible placement of a drain.

25. A postpartum woman presents to the perinatal clinic complaining of extreme breast tenderness and an inability to express milk on the left side when breastfeeding. What nonpharmacological comfort measure does the nurse teach this patient? A. Application of either warm or cold packs B. Expression of milk every 1-2 hours C. Ice and elevation of the breast when sitting D. Menthol-based lotion to draw the heat out

ANS: A This woman has the manifestations of mastitis and will be treated with antibiotics and analgesics. Comfort measures include applying either warm or cold packs to the breasts. If the woman wishes to continue breastfeeding, she should empty her breasts every 2-4 hours. Elevation and menthol-based lotions are not warranted.

32. A postpartum woman is in the perinatal clinic for a routine follow-up visit with her new infant. The patient seems agitated by the questions the nurse is asking and often looks up at the ceiling apprehensively. What action by the nurse is best? A. Ask the woman if she is hearing voices. B. Assess the woman's sleep and nutrition. C. Determine if the woman has any support. D. Take the baby to another room for assessment.

ANS: A This woman may be displaying signs of postpartum psychosis, which include hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality. The most specific question the nurse can ask is about hallucinations because the woman is looking up at the ceiling. Many new mothers have sleep disturbances, so this would not be the priority question to ask. Assessing the woman's social support is not a priority. Taking the infant away from the mother would only be needed if the infant were in immediate danger, and this action may agitate the woman further. The nurse should alert others, remain with the mother, and conduct further assessments.

1. As a member of the health-care team, the perinatal nurse finds it helpful following a maternal emergency, such as a postpartum hemorrhage, to engage in which of the following activities? (Select all that apply.) A. A family meeting to encourage communication and understanding B. Debriefing with the other staff members involved in the patient's care C. Health-promoting behaviors such as adequate sleep and exercise D. Review of the case to determine any fault in the care provided E. Time off to resolve any conflict with other staff members

ANS: A, B, C After the crisis has passed and immediate interventions have been completed, a debriefing of the healthcare team's response to the situation can be helpful as a learning opportunity. It is important to note the family's response to the unforeseen events and to include them, as appropriate, in the discussion. Because most families expect childbirth to be uneventful, a postpartum hemorrhage can provoke widely differing emotional responses. The prudent and compassionate clinician will take the time to let both the patient and the family express their feelings and affirm their concerns. Taking care of oneself is always helpful to decrease stress. The other actions are not helpful.

4. A woman is hospitalized after an incision and drainage of a large breast abscess that cultured methicillin-resistant Staphylococcus aureus. What dietary choices indicate that she has understood teaching regarding nutrition and wound healing? (Select all that apply.) A. Chicken breast B. Hard-boiled egg C. Orange slices D. Spinach E. Whole-wheat bread

ANS: A, B, C, D Wound healing and recovery from illness require high protein and vitamin C. Foods high in protein include animal products such as fish, chicken, beef, pork, seafood, lamb, eggs, cheese, and milk. Foods high in vitamin C include many fruits (cantaloupe, kiwi, oranges, papaya) and vegetables (spinach, brussels sprouts, and all colors of bell peppers). Whole-wheat bread, although a healthy choice, is not a good source of either protein or vitamin C.

7. The nursing faculty member explains to a class of nursing students the risk factors for developing postpartum depression (PPD). Which of the following does the faculty include? (Select all that apply.) A. Financial stress B. Isolation C. Low self-esteem D. Stay-at-home mother E. Unplanned pregnancy

ANS: A, B, C, E Risk factors for PPD include undesired/unplanned pregnancy, history of depression, recent major life change, isolation due to lack of family/social support or recent move into a new community, financial stress, marital problems, being an adolescent, low self-esteem, and homelessness. Being a stay-at-home mother may or may not cause financial stress, so the nurse would have to assess this condition further.

6. A postpartum woman has a suspected deep vein thrombosis (DVT). Which diagnostic studies does the nurse prepare the woman to possibly have? (Select all that apply.) A. Laboratory draw for D-dimer B. Magnetic resonance imaging (MRI) C. Venogram D. Venous duplex ultrasound E. Ventilation-perfusion (V/Q) scan

ANS: A, B, D Diagnostic tests for DVT include D-dimer (a fibrin degradation product), venous duplex ultrasound, and possibly an MRI. The venogram is contraindicated in pregnancy. A V/Q scan might be ordered if a question of pulmonary embolism existed, but in pregnancy, a spiral CT scan would be the better option.

10. A woman presents to the emergency department in labor and states that she is homeless and has not had prenatal care. The emergency department nurse explains to the nursing student that homeless women face many challenges to getting prenatal care, including which of the following? A. Caring for other children B. Fear of violence C. Lack of insurance D. Mistrust of health-care providers E. Transportation difficulties

ANS: A, C, D, E Many barriers exist that discourage homeless women from seeking prenatal care, including waiting times, lack of transportation, caring for other children, lack of family support and encouragement, concerns about having children taken away from them, and finances. Fear of violence is not a recognized risk factor for lack of prenatal care in this population.

2. The nursing faculty member who is explaining uterine atony to nursing students informs them of risk factors contributing to this condition. Which factors would place a woman at higher risk of uterine atony? (Select all that apply.) A. Forceps-assisted birth B. Trial of labor after a prior cesarean birth C. Multi-fetal gestation D. Oxytocin labor induction E. Use of magnesium sulfate

ANS: A, C, D, E Multiple factors increase the risk of uterine atony, including trauma during birth from forceps or vacuum devices; uterine overdistention from multi-fetal gestation, hydramnios, or macrosomia; and the use of both oxytocin and magnesium sulfate. (Other risk factors can be found in Box 16-1.) A trial of labor after a prior cesarean birth is not a risk factor for uterine atony.

12. A postpartum woman who had a prolonged labor presents to the clinic complaining of abdominal pain, high fevers with chills, and back pain. The nurse notes the patient's heart rate is 142 beats/minute, and her abdomen is tender with hypoactive bowel sounds. The patient will be admitted, and when giving report to the hospital nurse, the clinic nurse advises that the patient will probably receive what initial treatment? (Select all that apply.) A. Antibiotics B. Coumadin C. Forced fluids D. Heparin E. Ibuprofen (Motrin)

ANS: A, C, D, E This woman has manifestations of a septic pelvic thrombophlebitis. Initial treatment includes rest; compression stockings; a high-protein, high-vitamin C diet; antibiotics; increased fluids; heparin; and ibuprofen for fever and pain. Coumadin may be needed for long-term therapy but not as a first-line treatment.

1. The perinatal nurse is aware that a key factor contributing to suboptimal outcomes for pregnant women and their families is which of the following? A. Decreased knowledge regarding signs and symptoms of complications B. Delayed communication between health-care provider call groups C. Lack of family and other social support during pregnancy D. Suboptimal nursing resources to provide care during labor and birth

ANS: B Because perinatal care focuses on wellness, health promotion maintenance, and education for healthy women in multiple settings across the childbearing cycle, the danger of minimizing or misinterpreting pathological signs and symptoms is ever present. Delayed or absent communication between care provider call groups, combined with this wellness focus, can lead to suboptimal outcomes for women and their families.

34. A postpartum woman is about to be dismissed with her baby when she reveals to the nurse that she is homeless and has nowhere to go. What action by the nurse is most appropriate? A. Call Child Protective Services to come get the infant. B. Enlist social work to find a shelter that will take them. C. Remove the infant and take him to the newborn nursery. D. Tell the patient that the baby cannot be dismissed without a home.

ANS: B Caring for homeless women requires sensitivity and creativity. The best action by the nurse is to collaborate with social services to find a shelter that takes new moms and their infants. The other actions are unnecessary and will contribute to the woman's distrust of the health-care system.

10. A postpartum patient is hemorrhaging despite receiving several medications and fundal massage. What action by the nurse takes priority? A. Begin weighing all used perineal pads. B. Obtain informed consent for surgery. C. Place the woman on her left side. D. Switch the IV solution to dextrose.

ANS: B If more conservative methods do not control postpartum hemorrhage, invasive surgical procedures are indicated. Procedures include the placement of uterine packing, balloon tamponade, ligation of the uterine arteries, hypogastric artery ligation, uterine suturing, embolization procedures, and hysterectomy. The nurse needs to facilitate obtaining informed consent for an emergency invasive procedure. The nurse should already be weighing pads and linens. Placing the woman on her left side will not impact the bleeding. IV solutions should be normal saline, particularly if the woman will be receiving blood transfusions.

30. A woman with postpartum depression resists treatment, saying: "Who cares if I'm depressed? It only affects me." What response by the nurse is best? A. "Don't you think your family would like you to get treatment?" B. "Infants of depressed mothers have delayed development." C. "You may harm your baby if your depression is not treated." D. "We care that you are depressed and want you to feel better."

ANS: B Infants of mothers with depression are more likely to have delays in psychosocial and cognitive development and may be fussier than infants whose mothers are not depressed. Giving the woman factual information about a consequence of untreated depression may help her make a decision about treatment. The other statements are emotionally manipulative and are likely to induce guilt.

36. A woman with postpartum depression is in the perinatal clinic for follow-up. The health-care provider tells the nurse that the patient will be prescribed a tricyclic antidepressant. The nurse will instruct the patient about which medication? A. Fluoxetine (Prozac) B. Pamelor (Nortriptyline) C. Sertraline (Zoloft) D. Venlafaxine (Effexor)

ANS: B Pamelor is a tricyclic antidepressant. Prozac and Zoloft are selective serotonin reuptake inhibitors (SSRIs). Effexor is a serotonin-norepinephrine reuptake inhibitor (SNRI).

13. A patient is being dismissed after giving birth and having a hematoma drained in the operating room. What action by the patient best indicates to the nurse that outcomes for the diagnosis of risk for altered attachment have been met? A. Asks partner to hold the baby so she can sleep B. Holds and comforts the infant when fussy C. Makes eye contact with the infant D. States that her mother will help with infant care

ANS: B Patients are at risk for altered attachment when complications interfere with normal postpartum recovery. The best indication of resolution of this nursing diagnosis is the mother demonstrating care and concern for the baby by actively participating in the baby's care. Having resources to help with baby care is important, but does not demonstrate a lack of altered attachment. Making eye contact is a positive assessment finding, but is not as good of an indicator as actively caring for the baby.

21. A woman is being taken to the operating room later in the day for incision and drainage of a large perineal hematoma. What action by the nurse is most important to meet the patient's psychosocial needs? A. Administer a preoperative sedative to calm her. B. Allow the woman to make choices when possible. C. Introduce the patient to the nursery staff. D. Reassure the patient that hematomas heal quickly.

ANS: B Patients with postpartum complications often feel a lack of control. Allowing the woman to make choices whenever possible helps her regain her sense of control. Giving a sedative is merely masking the problem. Reassuring the woman may be important to do but is not the best response. Introducing the patient to the nursery staff would be a good action if that staff will be caring for the baby while the patient is in the operating room, but it is not the best option.

33. A nursing student who once lived in the southwest was overheard making disparaging comments about Hispanic immigrants, stating: "They only come here for free medical care." What response by the nursing faculty member is best? A. "Most immigrants do not come here for free health care at all." B. "Research actually shows that most immigrants come to find work." C. "That is a downfall of the Patient Protection and Affordable Care Act." D. "Why are you only picking one ethnic group about whom to make this statement?"

ANS: B Recent research showed that most undocumented Hispanic immigrants in Texas came to find work as their primary reason. This response is best because it offers factual information and is professional in tone. The Patient Protection and Affordable Care Act does not provide health coverage for undocumented migrants and prohibits them from buying private insurance from the state-sponsored exchanges.

24. A nurse is teaching a postpartum patient about preventing infection after discharge. What action by the patient indicates that she needs additional teaching? A. Allows milk to dry on her nipples after nursing B. Removes her peri-pad from back to front C. Sprays water from the peri-bottle from front to back D. Washes her hands prior to using the bathroom

ANS: B Removing the peri-pad from back to front increases the likelihood of contaminating the vaginal area with organisms from the rectal area. The other actions are appropriate.

6. A nursing student is preparing to give a pregnant woman heparin for a deep vein thrombosis (DVT). The student questions the dose, as it is higher than what the student has given to other patients. What response by the perinatal nurse is most appropriate? A. Have the student hold the dose and double-check the order with the provider. B. Inform the student that physiological changes in pregnancy require higher doses. C. Remind the student that large doses are needed to dissolve the existing clot. D. Tells the student to administer the dose and check results of the next laboratory draw.

ANS: B The pregnant patient has a greater plasma volume and an increased renal clearance (due to increased blood flow to the kidneys). The combination of normally occurring heparin-binding proteins along with the breakdown of heparin often results in the need for higher doses of heparin during pregnancy.

11. A nurse manager in the perinatal clinic wants to begin screening male partners for risk factors for committing intimate partner abuse. What risk factors does the manager include on the new screening form? (Select all that apply.) A. Confidence B. Low income C. Male-dominant family structure D. Unemployment E. Young age

ANS: B, C, D, E Many risk factors for committing intimate partner abuse can be found in Table 16-7. Confidence is not a risk factor.

9. A perinatal nurse is teaching a woman who is in a violent relationship about safety-promoting behaviors. Which of the following does the nurse include in teaching? (Select all that apply.) A. Ask neighbors and family not to intervene. B. Begin hiding money and an extra set of keys. C. Find and safely store important documents. D. Photocopy and save utility and rent receipts. E. Remove weapons or bullets from the home.

ANS: B, C, D, E The nurse teaches the woman several safety-promoting behaviors, including hiding money and extra keys, removing weapons/bullets from the home, asking neighbors to call the police should they detect violence, establishing a code with family and friends, and obtaining and securing items such as important documents.

3. The perinatal nurse explains risk factors for hematoma formation to a group of nursing students. What risk factors does the nurse include in the teaching? (Select all that apply.) A. Cesarean birth B. Episiotomy C. Genital tract laceration D. Multiparity E. Prolonged second stage of labor

ANS: B, C, E Risk factors for hematoma development include genital tract lacerations, episiotomies, operative vaginal deliveries, a difficult or prolonged second stage of labor, and nulliparity.

5. A perinatal nurse explains to the nursing student that pregnant women have risk factors for deep vein thrombosis (DVT) as a result of their pregnancy. To which components of Virchow's triad is the nurse referring? (Select all that apply.) A. Dehydration B. Hypercoagulability C. Trauma to veins D. Vascular distention E. Venous stasis

ANS: B, E Virchow's triad refers to the pathophysiology of DVT. It includes hypercoagulability, venous stasis, and trauma to vessels. One or more of these factors must be present in order to develop DVT. Hypercoagulability and venous stasis are normal changes during pregnancy and increase a woman's risk of developing DVT. Vascular distension and dehydration are not part of Virchow's triad, although dehydration can lead to hypercoagulability.

37. A perinatal nurse is conducting an initial interview and assessment on a new patient in her first trimester of an unplanned pregnancy. The nurse discovers the patient was a victim of child abuse and her husband has left her and returned several times. The nurse should assess this patient for what other issue as the priority? A. Financial concerns B. Homelessness C. Intimate partner abuse D. Social isolation

ANS: C Although all options are possibilities, this woman has several risk factors for being a victim of intimate partner abuse (unplanned pregnancy, victim of child abuse, marital instability). The nurse should first assess for this (intimate partner abuse) before considering the other situations.

26. As part of a research study on deep vein thrombosis (DVT), a perinatal nurse is collecting blood samples in women at highest risk for factor V Leiden mutation. Which woman would the nurse approach as the priority? A. African American B. Asian American C. Caucasian American D. Hispanic American

ANS: C Approximately 5-7% of North American Caucasians, 2% of Hispanics, and 1% of African Americans have the factor V Leiden mutation. Asians do not have this gene and are not at risk for this mutation.

8. A G2 TPAL 2002 patient experienced a precipitous birth 90 minutes ago. Her infant weighed 4,200 g, and a repair of a second-degree laceration was needed following the birth. The nurse assesses that the patient's uterus is boggy and deviated to the right. The patient's vaginal bleeding has increased. Which action by the nurse takes priority? A. Assess the vital signs, including blood pressure and pulse. B. Call the health-care provider to examine the woman now. C. Massage the uterine fundus with continual lower-segment support. D. Measure and document each used perineal pad to assess blood loss.

ANS: C As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and to initiate immediate actions. While another member of the team calls the physician or nurse-midwife, the nurse should first locate the uterine fundus and initiate fundal massage.

35. A woman with a deep vein thrombosis (DVT) is receiving IV heparin therapy. Which nursing diagnosis does the nurse address as the priority? A. Altered family processes B. Pain C. Risk for injury D. Self-care deficit

ANS: C Heparin has many side effects, including a risk for bleeding. The patient on IV heparin is at high risk for injury. The other diagnoses are important, but safety takes priority.

28. A nurse is caring for a patient on heparin for a deep vein thrombosis (DVT) and realizes that the patient has received an overdose of the medication. When contacting the physician, what orders does the nurse anticipate? A. Laboratory draw for PT/INR; administer protamine sulfate. B. Laboratory draw for PT/INR; administer vitamin K. C. Laboratory draw for aPTT; administer protamine sulfate. D. Laboratory draw for aPTT; administer vitamin K.

ANS: C Heparin therapy is monitored with the aPTT (activated partial thromboplastin time). The antidote for heparin is protamine sulfate. PT (prothrombin time) and INR (international normalized ratio) are used to monitor warfarin sodium therapy, although in many places INR is totally replacing the PT. Vitamin K is the antidote to warfarin.

2. The perinatal nurse accurately defines postpartum hemorrhage to a group of nursing students by including a decrease in hematocrit levels from prebirth to postbirth by which percentage? A. 5% B. 8% C. 10% D. 15%

ANS: C Postpartum hemorrhage can be defined as a blood loss of greater than 500 mL after a vaginal birth or greater than 1,000 mL after a cesarean birth, a decrease in hematocrit levels by 10% from prebirth to postbirth levels, and the need for transfusion.

5. The perinatal nurse administers heparin as ordered to the postpartum woman with newly diagnosed deep vein thrombosis. The patient asks about the purpose of the medication. Which response by the nurse is best? A. Assists with breakdown of the thromboses B. Decreases clotting time and circulatory clotting factors C. Prevents extension of the clot and new clot formation D. Prevents the formation of any new clots only

ANS: C The primary purpose of heparin therapy is to prevent extension of the current clot and to prevent new clot formation. The other answers are not correct.

17. The clinic nurse sees a patient and her infant in the clinic for their 2-week follow-up visit. The woman appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. Which question would be most appropriate for the nurse to ask? A. "Do you have help at home?" B. "Is there anything wrong with your son?" C. "Tell me about the first few days at home." D. "What has happened? You look awful!"

ANS: C The woman's appearance and interaction with her baby are clues to postpartum depression. The nurse needs to assess the woman further. A nonthreatening way to open the dialogue might be to say: "Tell me about the first few days at home." This statement provides the new mother with an opportunity to share both positive and negative impressions.

22. A nurse is assessing a patient for a perineal hematoma. Which action by the nurse is most appropriate? A. Assist the woman to a knee-chest position with head down. B. Have the patient lie supine and place her legs in frog-leg position. C. Place the patient in a side-lying position and lift the upper buttock. D. Turn the woman side to side and lift the upper leg each time.

ANS: C To correctly assess for a perineal hematoma, assist the woman to a side-lying position and gently lift the upper buttock. Ask the patient to bear down and assess for full or bulging tissue, blue discoloration of tissue, and tenderness.

29. A patient was discharged from the hospital on warfarin sodium (Coumadin) and is now in the perinatal clinic for follow-up. Which of the following would best indicate to the nurse that goals for discharge teaching have been met? A. Chooses aspirin for pain relief B. Eats large salads three times a week C. Patient INR of 2.5 D. Patient aPTT of 2 times normal

ANS: C Warfarin therapy is monitored with the PT and INR, and in many places, the INR has replaced the PT. A therapeutic INR is 2-3.5. This patient's INR is therapeutic. Aspirin can potentiate the risk of bleeding when taken with warfarin. Green leafy vegetables contain vitamin K, which can counteract warfarin. The patient should eat a consistent amount of foods containing vitamin K and not binge occasionally. The aPTT is used to monitor heparin therapy.

8. A woman is hospitalized emergently for postpartum psychosis. For which of the following does the nurse prepare the patient as initial treatment? (Select all that apply.) A. Amphetamine and dextroamphetamine (Adderall) B. Electroconvulsive therapy (ECT) C. Lithium (Lithobid) D. Chlorpromazine (Thorazine) E. Diazepam (Valium)

ANS: C, D, E Initial treatment for postpartum psychosis often involves a combination of mood stabilizers such as lithium, antipsychotic medications such as chlorpromazine, and anxiolytics such as diazepam. Adderall is used to treat ADHD and ECT is usually not a first line treatment.

16. A patient has been transferred to an intensive care unit (ICU) after experiencing a pulmonary embolus. The patient is stable 24 hours later, but will remain in the unit for another day or two. At this time, the priority for the perinatal nurse is to provide the family with information about infant care and what other action? A. Advocate for infant visitation and breast pumping in the ICU if desired by the patient. B. Give the family information about the hospital policies and procedures, including visiting hours. C. Provide information about follow-up with her family physician after discharge from the hospital. D. Educate the family and patient about the patient's risk for future deep vein thrombosis.

ANS: A Any postpartum complication can psychosocially affect a patient and her family. Prolonged treatment or hospitalization may create financial hardships, negatively impact family relationships and attachment with the infant, or result in psychological-emotional or spiritual crises. Because the patient is now stable, the perinatal nurse should advocate for the patient to have a postpartum experience that is as normal as possible. Visiting hours in the ICU are best explained by the ICU staff. It is too early to provide specific information about follow-up. Teaching the family and patient about future risks is important, but is not as high of a priority as is seeing to the patient's psychosocial needs and infant bonding in the ICU.

19. A perinatal nurse receives reports from the nurse aide on four patients who all gave birth within the last 4 hours. Which patient should the nurse assess first? A. Blood loss of 850 mL during cesarean birth B. Exhausted mother wanting only to rest after childbirth C. Pulse consistently ranges from 82 to 90 beats/minute D. Systolic blood pressure change from 132 to 110 mm Hg

ANS: D A drop in blood pressure by 15%, maternal heart rate over 110 beats/minute, or an oxygen saturation less than 95% may indicate a postpartum hemorrhage. The nurse should assess the woman whose blood pressure has changed more than 15%. Blood loss of 850 mL during cesarean birth is not considered excessive. A pulse under 100 beats/minute is normal. A mother may well be exhausted and need to rest, particularly if her birthing experience was difficult or traumatic.

4. The perinatal nurse teaches the postpartum woman about warning signs regarding the development of postpartum infection. The nurse teaches that fever and which of the following symptoms need to be assessed by a health-care provider? A. Breast engorgement B. Diarrhea C. Emotional lability D. Uterine tenderness

ANS: D During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

23. A woman had a cesarean birth after a prolonged trial of labor. When assessing the patient, the nurse notes the patient is lethargic, has a pulse of 130 beats/minute, and states: "I'm glad I have so little lochia; I'm too tired to change my pad." What action by the nurse is most appropriate? A. Assess the amount of lochia on the peri-pad. B. Cluster the nursing care given to allow uninterrupted sleep. C. Have the woman get up and attempt to void. D. Take a full set of vital signs and call the provider.

ANS: D Signs of puerperal infection include tachycardia, malaise, uterine tenderness, and subinvolution. Lochia can be heavy and foul smelling or scant and odorless, depending on the offending organism. The nurse should take a full set of vital signs, perform a complete assessment, and notify the health-care provider.

15. A postpartum woman has a deep vein thrombosis. The patient states, "I feel anxious and have some pain in my chest." The patient's respiratory rate is 28 breaths per minute. The perinatal nurse should prepare to respond to which of the following conditions? A. Amniotic fluid embolus B. Myocardial infarction C. Pulmonary edema D. Pulmonary embolus

ANS: D The presence of dyspnea and tachypnea may signal pulmonary embolism. Pulmonary embolism is a complication of deep vein thrombosis (DVT) that occurs when part of a blood clot breaks away and travels to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs.