Exam 3 - Chapter 33 Flashcards
- The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is:
a. uterine atony.
b. uterine inversion.
c. vaginal hematoma.
d. vaginal laceration.
ANS: A
Uterine atony is marked hypotonia of the uterus. It is the leading cause of after birth hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient’s bleeding. Furthermore, if the woman is experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.
- A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to:
a. establish venous access.
b. perform fundal massage.
c. prepare the woman for surgical intervention.
d. catheterize the bladder.
ANS: B
The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her after birth hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the patient to eliminate any bladder distention that may be preventing the uterus from contracting properly.
- The perinatal nurse caring for the after birth woman understands that late postpartum hemorrhage (PPH) is most likely caused by:
a. subinvolution of the placental site.
b. defective vascularity of the decidua.
c. cervical lacerations.
d. coagulation disorders.
ANS: A
Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.
- Which woman is at greatest risk for early postpartum hemorrhage (PPH)?
a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress.
b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced.
c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor.
d. A primigravida in spontaneous labor with preterm twins.
ANS: B
Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency C-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.
- The first and most important nursing intervention when a nurse observes profuse after birth bleeding is to:
a. call the woman’s primary health care provider.
b. administer the standing order for an oxytocic.
c. palpate the uterus and massage it if it is boggy.
d. assess maternal blood pressure and pulse for signs of hypovolemic shock.
ANS: C
The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).
- When caring for a after birth woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:
a. absence of cyanosis in the buccal mucosa.
b. cool, dry skin.
c. diminished restlessness.
d. urinary output of at least 30 mL/hr.
ANS: D
Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.
- One of the first symptoms of puerperal infection to assess for in the after birth woman is:
a. fatigue continuing for longer than 1 week.
b. pain with voiding.
c. profuse vaginal bleeding with ambulation.
d. temperature of 38° C (100.4° F) or higher on two successive days starting 24 hours after birth.
ANS: D
After birth or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on two successive days of the first 10 after birth days, starting 24 hours after birth. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.
- Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance:
a. PPH is easy to recognize early; after all, the woman is bleeding.
b. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL after cesarean birth to define the condition as PPH.
c. if anything, nurses and doctors tend to overestimate the amount of blood loss.
d. traditionally PPH has been classified as early or late with respect to birth.
ANS: D
Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately PPH can occur with little warning and often is recognized only after the mother has profound symptoms. Traditionally a 500-mL blood loss after a vaginal birth and a 1000-mL blood loss after a cesarean birth constitute PPH. Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.
- A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________.
a. disseminated intravascular coagulation; asking for laboratory tests
b. von Willebrand disease; noting whether bleeding times have been extended
c. thrombophlebitis; using real-time and color Doppler ultrasound
d. coagulopathies; drawing blood for laboratory analysis
ANS: C
Pain and tenderness in the extremities, which show warmth, redness, and hardness, likely indicate thrombophlebitis. Doppler ultrasound is a common noninvasive way to confirm diagnosis.
- What PPH conditions are considered medical emergencies that require immediate treatment?
a. Inversion of the uterus and hypovolemic shock
b. Hypotonic uterus and coagulopathies
c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura
d. Uterine atony and disseminated intravascular coagulation
ANS: A
Inversion of the uterus and hypovolemic shock are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that require immediate treatment.
- What infection is contracted mostly by first-time mothers who are breastfeeding?
a. Endometritis
b. Wound infections
c. Mastitis
d. Urinary tract infections
ANS: C
Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are primiparas who are breastfeeding.
- Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for after birth hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the patient with von Willebrand disease who experiences a after birth hemorrhage is:
a. cryoprecipitate.
b. factor VIII and vWf.
c. desmopressin.
d. hemabate.
ANS: C
Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products such as factor VIII and vWf is an acceptable option for this patient. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice. Although the administration of this prostaglandin is known to promote contraction of the uterus during after birth hemorrhage, it is not effective for the patient who presents with a bleeding disorder.
- When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may:
a. have outbursts of anger.
b. neglect her hygiene.
c. harm her infant.
d. lose interest in her husband.
ANS: C
Thoughts of harm to oneself’ or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger, hygiene neglect, and loss of interest in her husband are attributable to PPD, the major concern would be the potential to harm herself or her infant.
- To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) without psychotic features:
a. means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist.
b. is more common among older, Caucasian women because they have higher expectations.
c. is distinguished by irritability, severe anxiety, and panic attacks.
d. will disappear on its own without outside help.
ANS: C
PPD is also characterized by spontaneous crying long after the usual duration of the baby blues. PPD, even without psychotic features, is more serious and persistent than after birth baby blues. It is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.
- To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) with psychotic features:
a. is more likely to occur in women with more than two children.
b. is rarely delusional and then is usually about someone trying to harm her (the mother).
c. although serious, is not likely to need psychiatric hospitalization.
d. may include bipolar disorder (formerly called “manic depression”).
ANS: D
Manic mood swings are possible. PPD is more likely to occur in first-time mothers. Delusions may be present in 50% of women with PPD, usually about something being wrong with the infant. PPD with psychosis is a psychiatric emergency that requires hospitalization.
