Chapter 24: Postpartum complications Flashcards
(47 cards)
- The perinatal nurse’s assessment while caring for a patient in the immediate postpartum period reveals that the patient is experiencing profuse bleeding. What is the most likely etiology for her bleeding?
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 postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient’s bleeding. Furthermore, if the patient 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.
- Which is a primary nursing responsibility when caring for a patient experiencing an obstetrical hemorrhage associated with uterine atony?
a. Establish venous access.
b. Perform fundal massage.
c. Prepare the patient 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 patient 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 patient to eliminate any bladder distension that may be preventing the uterus from contracting properly.
- A perinatal nurse caring for the postpartum patient 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 patient is at greatest risk for early postpartum hemorrhage (PPH)?
a. A primiparous patient being prepared for an emergency Caesarean birth for fetal
distress
b. A patient with severe pre-eclampsia on magnesium sulphate whose labour is
being induced
c. A multiparous patient with an 8-hour labour
d. A primigravida in spontaneous labour with preterm twins
ANS: B
Magnesium sulphate administration during labour 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 patient being prepared for an emergency Caesarean birth, the multiparous patient with 8-hour labour, and the primigravida in spontaneous labour are not at risk for early PPH.
- What is the initial priority nursing intervention when a nurse observes profuse postpartum bleeding?
a. Call the patient’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 (BP) and pulse for signs of hypovolemic shock.
ANS: C
The initial management of excessive postpartum 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.
- What is the most objective and least invasive assessment of adequate organ perfusion and oxygenation when caring for a postpartum patient experiencing hemorrhagic shock?
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.
- Which is one of the first symptoms of puerperal infection to assess for in the postpartum patient?
a. Fatigue continuing for longer than 1 week
b. Pain with voiding
c. Profuse vaginal bleeding with ambulation
d. Temperature of 38.6C
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. A temperature greater than 38C warrants further investigation for a puerperal infection. 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
- The perinatal nurse assisting with establishing lactation is aware that which action can minimize acute mastitis?
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 using 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.
- 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 patient is bleeding.
b. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL
after Caesarean 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 primary or secondary.
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 Caesarean birth constitute PPH. Health care personnel tend to underestimate blood loss by 33% to 55% in their subjective observations.
- A patient who has recently given birth states they have pain and tenderness in their leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. What should the nurse suspect, and then what should the nurse implement to confirm the diagnosis?
a. Disseminated intravascular coagulation; ask for laboratory tests.
b. von Willebrand disease; note whether bleeding times have been extended.
c. Thrombophlebitis; ask for ultrasound examination.
d. Coagulopathies; draw blood for laboratory analysis.
ANS: C
Pain and tenderness in the extremities that show warmth, redness, and hardness likely indicate thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.
- What postpartum hemorrhage (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 potentially life-threatening complications and 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 mothers who are breastfeeding and usually occurs after the first postpartum week?
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 patients who suffer this are breastfeeding and symptoms rarely appear before the end of the first postpartum week.
- What medication should the nurse expect to see ordered first for the patient with von Willebrand disease who experiences a postpartum hemorrhage?
a. Cryoprecipitate
b. Factor VIII and von Willebrand factor (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, it would not be the first medication ordered for this patient. Treatment with plasma products such as factor VIII and vWf are an acceptable option for this patient. Because of the repeated exposure to donor blood products and possible viruses, however, this is not the initial treatment of choice. Although the administration of the prostaglandin Hemabate is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the patient who presents with a bleeding disorder.
- The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Many patients experience a perinatal mood disorder (PMD). Which statement regarding PMD is essential for the nurse to be aware of when attempting to formulate a nursing plan?
a. PPD symptoms are consistently severe.
b. This syndrome affects only new mothers.
c. PPD can easily go undetected.
d. Only mental health professionals should teach new parents about this condition.
ANS: C
PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with patients having both good and bad days. Both mothers and fathers should be screened. PPD may also affect new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all patients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if symptoms occur.
- A patient gave birth to a 4500 g baby 1 hour ago. When completing the patient’s 15-minute assessment, they tell a nurse that they “feels all wet underneath.” The nurse discovers that both pads are completely saturated and that the patient is lying in a 10 cm-diameter puddle of blood. What is the nurse’s first action?
a. Call for help.
b. Assess the fundus for firmness.
c. Take their blood pressure.
d. Check the perineum for lacerations.
ANS: B
Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Assessing blood pressure is an important assessment with a bleeding patient; however, the top priority is to control the bleeding. If bleeding continues in the presence of a firm fundus, lacerations may be the cause.
- A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests
a. uterine atony.
b. lacerations of the genital tract.
c. perineal hematoma.
d. infection of the uterus.
ANS: B
Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm in the presence of uterine atony. A hematoma would develop internally. Swelling and discoloration would be noticeable; however, bright bleeding would not be. With an infection of the uterus there would be an odour to the lochia and systemic symptoms such as fever and malaise.
- What is one of the main concerns when a patient is diagnosed with postpartum depression (PPD)?
a. They may have outbursts of anger.
b. They may neglect their hygiene.
c. They may harm their infant.
d. They may lose interest in their partner.
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 their partner are attributable to PPD, the major concern would be the potential to harm themselves or their infant.
- What should the nurse know to provide adequate postpartum care to the patient experiencing postpartum depression (PPD)?
a. PPD means that the patient is experiencing the baby blues. In addition, she has a
visit with a counsellor or psychologist.
b. PPD is more common among older, White patients because they have higher
expectations.
c. PPD is distinguished by irritability and labile mood swings.
d. PPD 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, is more serious and persistent than postpartum baby blues. It is more common among younger mothers and those with less education. Most patients need professional help, including pharmacological intervention, to get through PPD.
- To provide adequate postpartum care, a nurse should be aware that postpartum psychosis
a. is more likely to occur in patients 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
Postpartum psychosis is commonly associated with the diagnosis of bipolar (or manic-depressive) disorder. Manic mood swings are possible. Once a patient has had one postpartum episode with psychotic features, there is a 30% to 50% likelihood of recurrence with each subsequent birth; therefore, it is not more likely to occur after the birth of a patient’s first child. Episodes of postpartum psychosis are typified by auditory or visual hallucinations and paranoid or grandiose delusions. Postpartum psychosis is a psychiatric emergency that requires hospitalization.
- 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 in self-care activities to help prevent postpartum depression. What is the most accurate statement as related to these activities?
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 patients.
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 80% 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 she is 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 “superpatient.” A telephone call to the hospital warm line may provide reassurance about lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.
- 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 all indicate that the parents are in denial.
- What is the basis for the most appropriate statement that the nurse can make to young bereaved parents?
a. Indicating that the parents now have an angel in heaven.
b. Expressing to the parents that the nurse understands how they feel.
c. Pointing out to them that they are young and will have future opportunities to be
parents.
d. Expressing to the parents that you are sorry for their loss.
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 the sense of helplessness and to say or do something that one might think would 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. The statement “You’re young and can have other children” is not a therapeutic response for the nurse to make.
- What options for saying goodbye would the nurse want to discuss with a patient 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. Ask the mother if she would like a picture taken of her baby after birth.
c. Ask the patient if she would like to see and hold her baby after birth.
d. Assist the family in deciding what funeral home is to be notified after the baby is
born.
ANS: C
Mothers and fathers may find it helpful to see the newborn after birth. The parents’ wishes should be respected. While interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents, the initial intervention should be related directly to the parents’ wishes with regard to seeing or holding their dead infant. Altho ugh information regarding burial arrangements may be relevant, it is not the most appropriate option at this time and can be discussed after the infant is born.
- A patient experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). They state they are just fine and want to go home as soon as possible. While a nurse is assessing their responses to their loss, they tell you that they had purchased some baby things and had picked out a name. On the basis of your assessment of the responses, what nursing intervention would the nurse do first?
a. Ready them for discharge.
b. Notify pastoral care to offer them a blessing.
c. Ask them if they would like to see what was obtained from their D&C.
d. Ask them what name they had picked out for their baby.
ANS: D
One way of actualizing the loss is to allow parents to name the infant. The nurse should follow this patient’s cues and inquire about naming the infant. The patient is looking for an opportunity to express their feelings of loss. Although it may be therapeutic to offer religious support, the nurse should take this opportunity to offer support by allowing the patient to talk about their feelings. Asking the patient if they would like to see what was obtained from her D&C is completely inappropriate.
