Chapter 23 Postpartum Complications Flashcards Preview

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Flashcards in Chapter 23 Postpartum Complications Deck (41):
1

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. c. Vaginal hematoma.
b. Uterine inversion. d. Vaginal laceration.





ANS: A
Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this client’s bleeding. Furthermore, if the woman were 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.

2

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 postpartum 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 postpartum hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from contracting properly.

3

In helping bereaved parents cope and move on, nurses should keep in mind that:
a. A perinatal or parental grief support group is more likely to be helpful if the needs of the parents are matched with the focus of the group.
b. When pictures of the infant are taken for keepsakes, no close-ups should be taken of any congenital anomalies.
c. No significant differences exist in grieving individuals from various cultures, ethnic groups, and religions.
d. In emergency situations nurses who are so disposed must resist the temptation to baptize the infant in the absence of a priest or minister.

ANS: A
A perinatal or parental grief support group is more likely to be helpful if the needs of the parents are matched with the focus of the group. For example, a religious-based group may not work for nonreligious parents. Close-up pictures of the baby must be taken as the infant was, congenital anomalies and all. Although death and grieving are events shared by all people, mourning rituals, traditions, and taboos vary by culture, ethnicity, and religion. Differences must be respected. Baptism for some religious groups can be performed by a layperson such as a nurse in an emergency situation when a priest is not available.

4

Medications used to manage postpartum hemorrhage (PPH) include (choose all that apply):
a. Pitocin.
b. Methergine.
c. Terbutaline.
d. Hemabate.
e. Magnesium sulfate.

ANS: A, B, D
Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

5

Complicated bereavement:
a. Occurs when, in multiple births, one child dies, and the other or others live.
b. Is a state in which the parents are ambivalent, as with an abortion.
c. Is an extremely intense grief reaction that persists for a long time.
d. Is felt by the family of adolescent mothers who lose their babies.

ANS: C
Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, but this is not complicated bereavement. Abortion can generate complicated emotional responses, but they do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but this is not complicated bereavement.

6

With regard to organ donation after an infant’s death, nurses should be aware that:
a. Federal law requires medical staff to ask the parents about organ donation and then to contact their state’s organ procurement organization (OPO) to handle the procedure if the parents agree.
b. Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience.
c. The most common donation is the infant’s kidneys.
d. Corneas can be donated if the infant was either stillborn or alive, as long as the pregnancy went full term.

ANS: B
Some see organ donation as a healing experience. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation the infant must have been born alive at 36 weeks of gestation or later.

7

Nurses who want to help parents with their decision making about an autopsy or who may be required to be involved in seeking consent for autopsies should be aware that:
a. Autopsies not specifically covered by insurance or done under the jurisdiction of the medical examiner’s office can be very expensive.
b. Autopsies must be done within a few hours after delivery.
c. In the current litigious society more autopsies are performed than in the past.
d. Most parents who refuse the examination regret it later.

ANS: A
Autopsies can cost more than $3,000. There is no rush to perform an autopsy unless evidence of contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of medical facilities’ fear that errors by the staff might be revealed, resulting in litigation. Fewer than 15% of those who had refused an autopsy regretted it later.

8

When helping the mother, father, and other family members actualize the loss of the infant, nurses should:
a. Use the words lost or gone rather than dead or died.
b. Make sure that the family understands that it is important to name the baby.
c. If the parents choose to visit with the baby, apply powder and lotion to the baby and wrap the infant in a pretty blanket.
d. Set a firm time for ending the visit with the baby so the parents know when to let go.

ANS: C
Presenting the baby in a nice way stimulates the parents’ senses and provides pleasant memories of their baby. Nurses must use dead and died to assist the bereaved in accepting reality. Although naming the baby can be helpful, it is important not to create the sense that parents have to name the baby. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different time periods with their baby to say goodbye. Nurses need to be careful not to rush the process.

9

Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (choose all that apply):
a. Acupressure.
b. Aromatherapy.
c. St. John’s wort.
d. Wine consumption.
e. Yoga.

ANS: A, B, E
Possible alternative/complementary therapies for postpartum depression include acupuncture, acupressure, aromatherapy, therapeutic touch, massage, relaxation techniques, reflexology, and yoga. St. John’s wort has not been proven to be safe for women who are breastfeeding. Women who are breastfeeding and/or have a history of PPD should not consume alcohol.

10

The nurse would conclude that grieving parents had progressed to the reorganization/recovery phase during a follow-up visit a year later if:
a. The parents say they feel no pain.
b. The parents are discussing sex and a future pregnancy, even if they have not sorted out their feelings yet.
c. The parents have abandoned those moments of bittersweet grief.
d. The parents’ questions have progressed from “Why?” to “Why us?”

ANS: B
Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly past the first year, when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, often on anniversary dates. Most couples never abandon it. Recovery is ongoing. Typically a couple’s search for meaning progresses from “Why?” in the acute phase to “Why me?” in the intense phase to “What does this loss mean to my life?” in the reorganizational phase.

11

During a follow-up visit, if parents have progressed to the second stage or phase of grieving, the nurse should not expect to see:
a. Guilt, particularly in the mother.
b. Numbness or lack of response.
c. Bitterness or irritability.
d. Fear and anxiety, especially about getting pregnant again.

ANS: B
The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, as if the parents were still in denial or shock.

12

The nurse caring for a family during a loss might notice that survival guilt sometimes is felt at the death of an infant by the child’s:
a. Siblings. c. Father.
b. Mother. d. Grandparents.

ANS: D
Survival guilt sometimes is felt by grandparents, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not.

13

_________________________ refers to the grief response that occurs with reminders of loss. This typically happens on special anniversary dates of the loss.

ANS: Bittersweet grief

14

A woman is diagnosed with having a stillborn. At first, she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called:
a. Anticipatory grief. c. Intense grief.
b. Acute distress. d. Reorganization.


ANS: B
The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant’s possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

15

A woman experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). She states that she is just fine and wants to go home as soon as possible. While you are assessing her responses to her loss, she tells you that she had purchased some baby things and had picked out a name. On the basis of your assessment of her responses, what nursing intervention would you use first?
a. Ready her for discharge.
b. Notify pastoral care to offer her a blessing.
c. Ask her if she would like to see what was obtained from her D&C.
d. Ask her what name she had picked out for her baby.

ANS: D
One way of actualizing the loss is to allow parents to name the infant. The nurse should follow this client’s cues and inquire about naming the infant. The client is looking for an opportunity to express her feelings of loss. The nurse should take this opportunity to offer support by allowing the woman to talk about her feelings. Furthermore, one way of actualizing the loss is to allow parents to name the infant. The nurse should follow this client’s cues and inquire about naming the infant. Although it may be therapeutic to offer religious support, the nurse should take this opportunity to offer support by allowing the woman to talk about her feelings. Furthermore, one way of actualizing the loss is to allow parents to name the infant. Asking the woman if she would like to see what was obtained from her D&C is completely inappropriate.

16

What options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl?
a. The nurse shouldn’t discuss any options at this time; there is plenty of time after the baby is born.
b. “Would you like a picture taken of your baby after birth?”
c. “When your baby is born, would you like to see and hold her?”
d. “What funeral home do you want notified after the baby is born?”

ANS: C
Mothers and fathers may find it helpful to see the infant after delivery. The parents’ wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. Although this may be an intervention, the initial intervention should be related directly to the parents’ wishes with regard to seeing or holding their dead infant. Although this information may be relevant, it is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

17

What 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 on magnesium sulfate 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.

18

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurse’s role should be to:
a. Take over as much as possible to relieve the pressure.
b. Encourage grandparents to take over.
c. Make sure the parents themselves approve the final decisions.
d. Let them alone to work things out.

ANS: C
The nurse is always the client’s advocate. Nurses can offer support and guidance and leave room for the same from grandparents. However, in the end nurses should strive to let the parents make the final decisions.

19

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by:
a. Subinvolution of the placental site. c. Cervical lacerations.
b. Defective vascularity of the decidua. 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.

20

When caring for a postpartum 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 in nature. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

21

____________________ is the most common postpartum infection.

ANS: Endometritis

22

After giving birth to a stillborn infant, the woman turns to the nurse and says, “I just finished painting the baby’s room. Do you think that caused my baby to die?” The nurse’s best response to this woman is:
a. “That’s an old wives’ tale; lots of women are around paint during pregnancy, and this doesn’t happen to them.”
b. “That’s not likely. Paint is associated with elevated pediatric lead levels.”
c. Silence.
d. “I can understand your need to find an answer to what caused this. What else are you thinking about?”


ANS: D
The statement, “I can understand your need to find an answer to what caused this. What else are you thinking about?” is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grief. Trying to give bereaved parents answers when no clear answers exist does not help the grief process. In addition, this response probably would increase the mother’s feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. The nurse should encourage the mother to express her ideas.

23

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son’s prognosis. When the father sees his son, he says, “He looks just fine to me. I can’t understand what all this is about.” The most appropriate response by the nurse would be:
a. “Didn’t the doctor tell you about your son’s problems?”
b. “This must be a difficult time for you. Tell me how you’re doing.”
c. To stand beside him quietly.
d. “You’ll have to face up to the fact that he is going to die sooner or later.”

ANS: B
The grief phase can be very difficult, especially for fathers. Parents should be encouraged to share their feelings as the initial steps in the grieving process. This father is in a phase of acute distress and is “reaching out” to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through sharing and verbalization of feelings of grief. “You’ll have to face up to the fact that he is going to die sooner or later” is dispassionate and inappropriate statement.

24

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action would indicate that the family had begun to grieve for the dead infant?
a. They refer to the two live infants as twins.
b. They ask about the dead triplet’s current status.
c. They bring in play clothes for all three infants.
d. They refer to the dead infant in the past tense.

ANS: D
Accepting that the infant is dead (in the past tense of the word) demonstrates acceptance of the reality and that the family has begun to grieve. Referring to the two live infants as twins, asking about the dead infant’s current status, and bringing clothing for all three infants indicate that the parents are still in denial.

25

The most appropriate statement that the nurse can make to bereaved parents is:
a. “You have an angel in heaven.”
b. “I understand how you must feel.”
c. “You’re young and can have other children.”
d. “I’m sorry.”

ANS: D
One of nurse’s most important goals is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment such as, “I’m sorry.” The initial impulse may be to reduce one’s sense of helplessness and say or do something that you think will reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. Saying, “You’re young and can have other children” is not a therapeutic response for the nurse to make.

26

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to:
a. Stay home and avoid outside activities to ensure adequate rest.
b. Be certain that you are the only caregiver for your baby to facilitate infant attachment.
c. Keep feelings of sadness and adjustment to your new role to yourself.
d. Realize that this is a common occurrence that affects many women.

ANS: D
Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of. As many as 15% of new mothers experience similar symptoms. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she not isolate herself at home during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant’s care. If depression occurs, the symptoms can often interfere with mothering functions and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be “superwoman.” A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.

27

According to Beck’s studies, what risk factor for postpartum depression is likely to have the greatest effect on the woman’s condition?
a. Prenatal depression c. Low socioeconomic status
b. Single-mother status d. Unplanned or unwanted pregnancy

ANS: A
Prenatal depression has been found by Beck to have the greatest likely effect. Single-mother status and low socioeconomic status are small-relation predictors, as is an unwanted pregnancy.

28

The first and most important nursing intervention when a nurse observes profuse postpartum 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 postpartum bleeding is firm massage of the uterine fundus. Though 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).

29

One of the first symptoms of puerperal infection to assess for in the postpartum 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 2 successive days starting 24 hours after birth.

ANS: D
Postpartum 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 2 successive days of the first 10 postpartum 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.

30

To provide adequate postpartum 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 postpartum 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.

31

To provide adequate postpartum 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 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.

32

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. c. Harm her infant.
b. Neglect her hygiene. d. Lose interest in her husband.


ANS: C
Thoughts of harm to one’s self 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.

33

The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by:
a. Washing the nipples and breasts with mild soap and water once a day.
b. Using proper breastfeeding techniques.
c. Wearing a nipple shield for the first few days of breastfeeding.
d. Wearing a supportive bra 24 hours a day.





ANS: B
Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. Washing the nipples and breasts daily is no longer indicated. In fact, this can cause tissue dryness and irritation, which can lead to tissue breakdown and infection. Wearing a nipple shield does not prevent mastitis. Wearing a supportive bra 24 hours a day may contribute to mastitis, especially if an underwire bra is worn, because it may put pressure on the upper, outer area of the breast, contributing to blocked ducts and mastitis.

34

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.

35

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. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.

36

The prevalence of urinary incontinence (UI) increases as women age, with more than one third of women in the United States suffering from some form of this disorder. The symptoms of mild-to-moderate UI can be successfully decreased by a number of strategies. Which of these should the nurse instruct the client to use first?
a. Pelvic floor support devices
b. Bladder training and pelvic muscle exercises
c. Surgery
d. Medications


ANS: B
Pelvic muscle exercises, known as Kegel exercises, along with bladder training can significantly decrease or entirely relieve stress incontinence in many women. Pelvic floor support devices, also known as pessaries, come in a variety of shapes and sizes. Pessaries may not be effective for all women and require scrupulous cleaning to prevent infection. Anterior and posterior repairs and even a hysterectomy may be performed. If surgical repair is performed, the nurse must focus her care on preventing infection and helping the woman avoid putting stress on the surgical site. Pharmacologic therapy includes serotonin-norepinephrine uptake inhibitors or vaginal estrogen therapy. These are not the first action a nurse should recommend.

37

A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems and sensations of bearing down and of something in her vagina. The nurse would realize that the client most likely is suffering from:
a. Pelvic relaxation. c. Uterine displacement.
b. Cystoceles and/or rectoceles. d. Genital fistulas.

ANS: B
Cystoceles are protrusions of the bladder downward into the vagina; rectoceles are herniations of the anterior rectal wall through a relaxed or ruptured vaginal fascia. Both can present as a bearing down sensation with urinary dysfunction. They occur more often in older women who have borne children.

38

The nurse should be aware that a pessary would be most effective in the treatment of what disorder?
a. Cystocele c. Rectocele
b. Uterine prolapse d. Stress urinary incontinence

ANS: B
A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct position. A pessary is not used for a cystocele, a rectocele, or stress urinary incontinence.

39

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 postpartum 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 client with von Willebrand disease who experiences a postpartum hemorrhage is:
a. Cryoprecipitate. c. Desmopressin.
b. Factor VIII and vWf. 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 are an acceptable option for this client. 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 postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

40

What infection is contracted mostly by first-time mothers who are breastfeeding?
a. Endometritis c. Mastitis
b. Wound infections d. Urinary tract infections

ANS: C
Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.

41

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 requires immediate treatment.