VSim Next-Gen Maternity Case 5: Fatime Sanogo
When performing the postpartum examination, the nurse finds the patient's fundus above the umbilicus and deviated to the right. What does the nurse know might be the cause of this finding?
A full bladder - When the bladder is full, it displaces the uterus upward and laterally, and the uterus is unable to contract effectively. The expected position of the uterus is midline. Retained placental tissue will interfere with contraction of the uterus but will not displace it. Constipation does not impact uterine tone or position.
A complication of postpartum hemorrhage is hemorrhagic shock. Which of the following set of signs would alert the nurse to the development of hemorrhagic shock?
Tachycardia, hypotension, and decreased urine output - Tachycardia, hypotension, and decreased urine output are signs of poor tissue perfusion and the body's attempt to compensate to maintain vital functions. They are consistent with the development of hemorrhagic shock. Bradycardia, decreased hematocrit levels, and low platelets are late signs of the body's response to the blood loss and the consequences of hypovolemic shock.
The nurse educates Fatime Sanago 8 hours postpartum. Which statement(s) by the patient indicate an understanding of postpartum hemorrhage? (Select all that apply.)
"I lost too much blood after the birth." , "I received several medications to help keep my uterus firm." , "If my iron levels are low and I feel weak, I may need a blood transfusion." , "I should not get out of bed for the first time without assistance from a nurse." , "I should call the nurse to check my bleeding if I feel a large gush." Assessing the patient's understanding of birth complications is a nursing priority. Therapeutic communication is a standard of care. The patient needs to understand the blood loss, medications provided, when to call for assistance, and the importance of maintaining an IV. The patient should be encouraged to continue breastfeeding, and there is no reason she cannot breastfeed due to the hemorrhage or medications. A patient who experienced a postpartum hemorrhage will be evaluated for anemia; it is common to consider a blood transfusion for a patient who is symptomatic and has a hemoglobin value of less than 7 g/dL. The IV will not be removed until
Fatime Sanogo's condition does not improve despite oxytocin infusion, urinary catheterization, and fundal massage. The nurse takes verbal orders from the provider, documents the orders, and reads them back. As the nurse, you read back the following: I am confirming a request to administer methylergonovine ( Choose Answer.. ) immediately and an order on hold for carboprost tromethamine ( Choose Answer.. ).
0.2 mg intramuscular injection, 250 mcg intramuscular, which I recommend we do not administer because the patient has asthma Methylergonovine (methergine) is an ergot derivative that is an appropriate uterotonic to treat postpartum hemorrhage. The dose is 0.2 mg IM. IV dosing should be considered only in life-threatening situations. Carboprost tromethamine (hemabate) is a prostaglandin that is an appropriate uterotonic to treat postpartum hemorrhage, but it is contraindicated in a patient with asthma because it can cause bronchospasm. The appropriate dose is 250 mcg IM every 15 to 90 minutes, as needed, to a total cumulative dose of 2 mg (eight doses). Diarrhea is a common side effect, but it is not a contraindication.
The nurse notifies the provider of Fatime Sanogo's condition, including a quantitative blood loss of 800 mL and ongoing bleeding. Which interventions are indicated for this patient? (Select all that apply.)
Administration of methylergonovine, Therapeutic communication, Quantification of blood loss, Type and crossmatch, Vital signs, Fundal massage Rationale: An important aspect of postpartum assessment includes evaluating the uterus for tone and position. Uterine involution normally begins immediately after vaginal delivery. When the uterus does not contract properly or remain firm, it is referred to as "boggy." A uterus that does not contract or remain firm during involution may result in uterine bleeding or hemorrhage. Fundal massage and vital signs are standard nursing interventions in the face of postpartum hemorrhage. Quantification of blood loss is a standardized process that allows for timely diagnosis of and early intervention for postpartum hemorrhage. A type and cross-match is a standard protocol in case a blood transfusion is necessary. Methylergonovine is an appropriate uterotonic for this patient, but carboprost tromethamine is contraindicated due to the patient's history of a
Which of the following is consistent with the definition of a massive obstetric hemorrhage?
Blood loss requiring transfusion of more than 5 units of blood - The definition of a massive obstetric hemorrhage is blood loss of more than 2,500 mL (84.5 oz) or blood loss requiring more than 5 units of transfused blood. Postpartum hemorrhage is defined as blood loss of 500 mL after vaginal birth or 1,000 mL after cesarean birth, but a more objective definition of postpartum hemorrhage would be any amount of bleeding that places the patient in hemodynamic jeopardy.
A patient is hemorrhaging after giving birth. When inspected, an area of the placenta was frayed. The provider suspects that placental fragments are retained within the uterus. What is the expected treatment for this condition?
Evacuation of the uterus followed by oxytocin administration - Evacuation of the retained tissue from the uterus is the first step. This is usually done manually by the provider. Then oxytocin is administered to help maintain uterine contraction. Uterine massage with the administration of methylergonovine maleate or oxytocin administration followed by carboprost tromethamine administration will stimulate contraction of the uterus while the placental fragments are still inside. Uterine inversion is a medical complication, not an intervention.
The provider orders two units of packed red blood cells to be available but on hold in the lab. Which laboratory test(s) should the nurse review? (Select all that apply.)
Hemoglobin, Hematocrit, Platelets, Type and crossmatch Rationale:The nurse should analyze the complete blood count, which includes hemoglobin, hematocrit, and platelets. A type and crossmatch, if not already done, is important in the process of blood transfusion. It is estimated that for every 500 mL of blood loss, the hemoglobin levels will fall 1 gm/dL. Hemoglobin is an indicator of the number of red blood cells, and the level drops during hemorrhage. Hematocrit is the percentage of red blood cells in the total blood volume, and the level also drops during hemorrhage. Platelets facilitate blood clotting, and a drop in the platelet level puts the patient at risk for an increase in bleeding. Hemoglobin A1C is a clinical test used in the diagnosis and management of diabetes. Troponin levels are measured to evaluate for myocardial infarction. The Kleihauer Betke test is used to evaluate for fetal blood in maternal circulation. Albumin is a protein in the blood plasma that is evaluated to
Which of the following are contraindications to the administration of misoprostol for treatment of a postpartum hemorrhage? (Select all that apply.)
Hepatitis C, Asthma - Presence of pulmonary or hepatic disease is a contraindication for the use of prostaglandin medications.
The nurse completes a postpartum assessment on Fatime Sanogo, who gave birth vaginally 1 hour ago. Which assessment finding(s) require immediate follow-up? (Select all that apply.)
Quantitative blood loss 800 mL, BP 90/50 mm Hg, HR 120 bpm, Patient reports feeling weak, Boggy uterus, Distended bladder Rationale:Postpartum hemorrhage is defined as loss of more than 500 mL of blood following vaginal delivery. A quantitative blood loss of 800 mL warrants timely recognition and intervention. Weakness, tachycardia (100 to 120 bpm), and systolic blood pressure 80 to 90 mm Hg are symptoms related to blood loss with postpartum hemorrhage. Uterine atony (boggy uterus) occurs when the uterus does not effectively contract after delivery and is a major cause of postpartum hemorrhage. A distended bladder exacerbates uterine atony. A history of asthma is not abnormal but will need to be noted because one of the medications given to treat a postpartum hemorrhage is contraindicated in patients with asthma. A temperature of 36.5ºC (97.7ºF) and SpO2 of 96% on room air are normal vital sign parameters.
Which of the following factor(s) places a patient at risk for postpartum hemorrhage? (Select all that apply.)
Rapid labor, Macrosomia, Maternal fever, Oxytocin use during labor - Rapid labor, macrosomia, and oxytocin use during labor all place additional stress on the uterine muscle and may lead to muscle fatigue and failure of the muscle to effectively contract post-birth. Maternal fever indicating intrauterine infection may also impair the effectiveness of the uterine muscle to contract and control bleeding from the placental site. Preterm birth is not a risk factor for postpartum hemorrhage.
While assessing the patient's fundus, the nurse notes that with massage the uterus becomes firm, but then it relaxes again and the bleeding increases. Which of the following causes of excessive bleeding does the nurse suspect?
Retained tissue- The presence of retained placental tissue prevents contraction of the uterine muscle and occlusion of vessels at the placental site. With uterine atony, the uterus does not firm up with massage. With a laceration, there is excessive bleeding in the presence of a firm uterus. A hematoma is not related to the tone of the uterus.
Why should the patient's level of consciousness be assessed during management of postpartum hemorrhage?
To evaluate cerebral perfusion - Level of consciousness will provide data about the adequacy of cerebral perfusion. With loss of blood volume, perfusion of vital organs, such as the brain, is at risk. The patient's cognitive abilities, understanding of the situation, and competence to make medical decisions are not parameters to assess cerebral perfusion.
Following the administration of misoprostol for management of postpartum hemorrhage, which of the following is the priority nursing assessment?
Uterine tone - Continuous contraction of the uterus is the goal of postpartum hemorrhage interventions, and misoprostol is used to stimulate uterine contraction. Therefore, assessing uterine tone is the priority assessment to evaluate the effectiveness of this medication.
During the first 30 to 45 minutes of a postpartum hemorrhage, which of the following is the best parameter to evaluate the amount of blood loss?
Weighing pads - Due to the increased blood volume of pregnancy, vital signs and urine output do not reflect bleeding until approximately 1,800 mL (60.9 oz) of blood has been lost. Therefore, early evaluation of the degree of blood loss are based on weighing pads to quantify blood loss.
If Fatime Sanogo's hemorrhage progresses to greater than 1500 mL with ongoing excessive bleeding 4 hours after birth, the nurse would recognize that the patient is at greatest risk for ( Choose Answer.. ) and would most likely require ( Choose Answer.. ).
hemorrhagic shock, blood and blood products Hemorrhagic shock is a form of hypovolemic shock in which severe blood loss leads to inadequate oxygen delivery at the cellular level. Amniotic fluid embolism occurs when amniotic fluid enters the maternal circulation. It most often occurs during birth. Immune thrombocytopenic purpura (ITP) is characterized by autoimmune platelet destruction (e.g., systemic lupus erythematosus). Preeclampsia is new-onset hypertension and end organ dysfunction. Amniotic fluid embolism, preeclampsia, and ITP are not pertinent to Fatime Sanogo's history. A blood loss of greater than 1500 mL with ongoing excessive bleeding poses a high risk for hemorrhagic shock, requiring a massive transfusion protocol (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate). Replacement with blood components is more important than fluid resuscitation. A hypertonic solution (e.g., D5LR) is not compatible with a blood transfusion. Isotonic crystalloids (norma