Chapter 33

Question 1

1. A perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause for this bleeding?
   a. Uterine atony
   b. Uterine inversion
   c. Vaginal hematoma
   d. Vaginal laceration

Answer 1

ANS: A
Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage; however, it is not the most likely source of this client’s bleeding. Further, 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 for vaginal hematoma is pain, not the presence of profuse bleeding. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

Question 2

2. What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony?
   a. Establishing venous access
   b. Performing fundal massage
   c. Preparing the woman for surgical intervention
   d. Catheterizing the bladder

Answer 2

ANS: B
The initial management of excessive postpartum bleeding is a firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, fundal massage is the initial intervention. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention is 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 properly contracting.

Question 3

3. What is the most common reason for late postpartum hemorrhage (PPH)?
   a. Subinvolution of the uterus
   b. Defective vascularity of the decidua
   c. Cervical lacerations
   d. Coagulation disorders

Answer 3

ANS: A
Late PPH may be the result of subinvolution of the uterus. Recognized causes of subinvolution include retained placental fragments and pelvic infection. Although defective vascularity, cervical lacerations, and coagulation disorders of the decidua may also cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

Question 4

4. Which client is at greatest risk for early PPH?
   a. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
   b. Woman with severe preeclampsia on magnesium sulfate whose labor is being induced
   c. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
   d. Primigravida in spontaneous labor with preterm twins

Answer 4

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. A primiparous woman being prepared for an emergency cesarean birth for fetal distress, a multiparous woman with an 8-hour labor, and a primigravida in spontaneous labor with preterm twins do not indicate risk factors or causes of early PPH.

Question 5

5. The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
   a. Absence of cyanosis in the buccal mucosa
   b. Cool, dry skin
   c. Calm mental status
   d. Urinary output of at least 30 ml/hr

Answer 5

ANS: D
Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation during 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 is associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

Question 6

6. The most effective and least expensive treatment of puerperal infection is prevention. What is the most important strategy for the nurse to adopt?
   a. Large doses of vitamin C during pregnancy
   b. Prophylactic antibiotics
   c. Strict aseptic technique, including hand washing, by all health care personnel
   d. Limited protein and fat intake

Answer 6

ANS: C
Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is extremely important and the least expensive measure to prevent infection. Good nutrition to control anemia is a preventive measure. Increased iron intake assists in preventing anemia. Antibiotics may be administered to manage infections; they are not a cost-effective measure to prevent postpartum infection. Limiting protein and fat intake does not help prevent anemia or prevent infection.

Question 7

7. What is one of the initial signs and symptoms of puerperal infection in the postpartum client?
   a. Fatigue continuing for longer than 1 week
   b. Pain with voiding
   c. Profuse vaginal lochia with ambulation
   d. Temperature of 38° C (100.4° F) or higher on 2 successive days

Answer 7

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 is a late finding associated with infection. Pain with voiding may indicate a urinary tract infection (UTI), 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.

Question 8

8. Nurses need to understand the basic definitions and incidence data regarding PPH. Which statement regarding this condition is most accurate?
   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 physicians tend to overestimate the amount of blood loss.
   d. Traditionally, PPH has been classified as early PPH or late PPH with respect to birth.

Answer 8

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 is often 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.

Question 9

9. 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. Which condition should the nurse suspect, and how will it be confirmed?
   a. Disseminated intravascular coagulation (DIC); asking for laboratory tests
   b. von Willebrand disease (vWD); noting whether bleeding times have been extended
   c. Thrombophlebitis; using real-time and color Doppler ultrasound
   d. Idiopathic or immune thrombocytopenic purpura (ITP); drawing blood for laboratory analysis

Answer 9

ANS: C
Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound examination is a common noninvasive way to confirm the diagnosis. A diagnosis of DIC is made according to clinical findings and laboratory markers. With DIC, a physical examination will reveal symptoms that may include unusual bleeding, petechiae around a blood pressure cuff on the woman’s arm, and/or excessive bleeding from the site of a slight trauma such as a venipuncture site. Symptoms of vWD, a type of hemophilia, include recurrent bleeding episodes, prolonged bleeding time, and factor VIII deficiency. A risk for PPH exists with vWD but does not exhibit a warm or reddened area in an extremity. ITP is an autoimmune disorder in which the life span of antiplatelet antibodies is decreased. Increased bleeding time is a diagnostic finding, and the risk of postpartum uterine bleeding is increased.

Question 10

10. Which classification of placental separation is not recognized as an abnormal adherence pattern?
    a. Placenta accreta
    b. Placenta increta
    c. Placenta percreta
    d. Placenta abruptio

Answer 10

ANS: D
Placenta abruptio is premature separation of the placenta as opposed to partial or complete adherence. This classification occurs between the 20th week of gestation and delivery in the area of the decidua basalis. Symptoms include localized pain and bleeding. Placenta accreta is a recognized degree of attachment. With placenta accreta, the trophoblast slightly penetrates into the myometrium. Placenta increta is a recognized degree of attachment that results in deep penetration of the myometrium. Placenta percreta is the most severe degree of placental penetration that results in deep penetration of the myometrium. Bleeding with complete placental attachment occurs only when separation of the placenta is attempted after delivery. Treatment includes blood component therapy and, in extreme cases, hysterectomy may be necessary.

Question 11

11. Which condition is considered a medical emergency that requires immediate treatment?
    a. Inversion of the uterus
    b. Hypotonic uterus
    c. ITP
    d. Uterine atony

Answer 11

ANS: A
Inversion of the uterus is likely to lead to hypovolemic shock and therefore is considered a medical emergency. Although hypotonic uterus, ITP, and uterine atony are serious conditions, they are not necessarily medical emergencies that require immediate treatment.

Question 12

12. Which is the initial treatment for the client with vWD who experiences a PPH?
    a. Cryoprecipitate
    b. Factor VIII and von Willebrand factor (vWf)
    c. Desmopressin
    d. Hemabate

Answer 12

ANS: C
Desmopressin is the primary treatment of choice for vWD and 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 client. Because of the repeated exposure to donor blood products and possible viruses, this modality is not the initial treatment of choice. Although the administration of the prostaglandin, Hemabate, is known to promote contraction of the uterus during PPH, it is not effective for the client who has a bleeding disorder.

Question 13

13. What would a steady trickle of bright red blood from the vagina in the presence of a firm fundus suggest to the nurse?
    a. Uterine atony
    b. Lacerations of the genital tract
    c. Perineal hematoma
    d. Infection of the uterus

Answer 13

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, an odor to the lochia and systemic symptoms such as fever and malaise would be present.

Question 14

14. If nonsurgical treatment for late PPH is ineffective, which surgical procedure would be appropriate to correct the cause of this condition?
    a. Hysterectomy
    b. Laparoscopy
    c. Laparotomy
    d. Dilation and curettage (D&C)

Answer 14

ANS: D
D&C allows the examination of the uterine contents and the removal of any retained placental fragments or blood clots. Hysterectomy is the removal of the uterus and is not the appropriate treatment for late PPH. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity, but it, too, is not the appropriate treatment for this condition. A laparotomy is the surgical incision into the peritoneal cavity to explore it but is also not the appropriate treatment for late PPH.

Question 15

1. Which medications are used to manage PPH? (Select all that apply.)
   a. Oxytocin
   b. Methergine
   c. Terbutaline
   d. Hemabate
   e. Magnesium sulfate

Answer 15

ANS: A, B, D
Oxytocin, Methergine, and Hemabate are medications used to manage PPH. Terbutaline and magnesium sulfate are tocolytic medications that are used to relax the uterus, which would cause or worsen PPH.

Question 16

2. Lacerations of the cervix, vagina, or perineum are also causes of PPH. Which factors influence the causes and incidence of obstetric lacerations of the lower genital tract? (Select all that apply.)
   a. Operative and precipitate births
   b. Adherent retained placenta
   c. Abnormal presentation of the fetus
   d. Congenital abnormalities of the maternal soft tissue
   e. Previous scarring from infection

Answer 16

ANS: A, C, D, E
Abnormal adherence of the placenta occurs for unknown reasons. Attempts to remove the placenta in the usual manner can be unsuccessful, and lacerations or a perforation of the uterine wall may result. However, attempts to remove the placenta do not influence lower genital tract lacerations. Lacerations of the perineum are the most common of all lower genital tract injuries and often occur with both precipitate and operative births and are classified as first-, second-, third-, and fourth-degree lacerations. An abnormal presentation or position of the fetus, the relative size of the presenting part, and the birth canal may contribute to lacerations of the lower genital tract. Congenital abnormalities, previous scarring from infection or injury, and a contracted pelvis may also influence injury to the lower genital tract, followed by hemorrhage.

Question 17

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.

Answer 17

Ans: C
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus to stop the bleeding. This is the most important nursing intervention. Then the primary health care provider should be notified or the nurse can delegate this task to another staff member. Administering an oxytocic and ascertaining vital signs are appropriate after assessment has been made and immediate steps have been taken to control the bleeding.

Question 18

Which 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 (ITP)
d. Uterine atony and disseminated intravascular coagulation (DIC).

Answer 18

Ans: A
Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin; coagulopathies should have been identified prior to delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment; ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications but are not medical emergencies requiring immediate intervention.

Question 19

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding?

a. Endometritis
b. Wound infections
c. Mastitis
d. Urinary tract infections (UTIs)

Answer 19

Ans: C
Mastitis is infection in a breast, usually confined to a milk duct. Most women who get it are first-timers who are breastfeeding. Endometritis is the most common postpartum infection. Its incidence is higher after a cesarean birth, not in first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal exams, and epidural anesthesia.

Question 20

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 rise naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum as levels of von Willebrand factor (vWf) and factor VIII fall. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is:

a. Cryoprecipitate
b. Factor VIII and vWf
c. Desmopressin
d. Hemabate

Answer 20

Ans: C
Desmopressin is the primary treatment of choice. This hormone, which can be administered orally, nasally, and intravenously, promotes the release of factor VIII and vWf from storage. Treatment with cryoprecipitate or with plasma products such as factor VIII and vWf is acceptable, but because of the associated risk of possible viruses from donor blood products, other modalities are considered safer. Although the administration of the synthetic prostaglandin in Hemabate is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

Question 21

During rounds, a nurse suspects that a patient who has recently delivered via vaginal route is having excessive postpartum bleeding. Which intervention would be the priority action taken by the nurse at this time?

a. Call the physician.
b. Massage the uterine fundus.
c. Increase the rate of intravenous fluids.
d. Monitor pad count and perform catheterization.

Answer 21

Ans: B
Massaging of the uterine fundus would be a priority action to help expel clots and stimulate uterine contractions to constrict blood flow. The other actions described, as well as catheterization (if bladder distention is noted) and lochia flow monitoring, may be needed, but none of them is the priority action required at this time.

Question 22

A thrombosis results from the formation of a blood clot or clots inside a blood vessel and is caused by inflammation or partial obstruction of the vessel. Three thromboembolic conditions are of concern during the postpartum period; which of the following is not?

a. Amniotic fluid embolism (AFE)
b. Superficial venous thrombosis
c. Deep vein thrombosis
d. Pulmonary embolism

Answer 22

Ans: A
An AFE occurs during the intrapartum period, when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis, the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis, occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs.

Question 23

Which of the following is the most common kind of placental adherence seen in pregnant women?

a. Accreta
b. Placenta previa
c. Percreta
d. Increta

Answer 23

Ans: A
Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient’s risk for painless vaginal bleeding during the pregnancy and/or delivery process. Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Placenta increta leads to deep penetration of the myometrium.

Question 24

Which ratio would be used to restore effective circulating volume in a postpartum patient who is experiencing hypovolemic shock?

a. 4:1
b. 2:1
c. 1:1
d. 3:1

Answer 24

Ans: D

A 3:1 ratio, of 3 ml fluid infused for every 1 ml of estimated blood loss, is recommended to restore circulating volume.

Question 25

Which indicator would lead the nurse to suspect that a postpartum patient experiencing hemorrhagic shock is getting worse?

a. Restoration of blood pressure levels to normal range
b. Capillary refill brisk
c. Patient complaint of headache and increased reaction time to questioning
d. Patient statement that she sees “stars”

Answer 25

Ans: C
Patient complaint of a headache accompanied by an increased reaction (response) time indicates that cerebral hypoxia is getting worse. Return of blood pressure to normal range would indicate resolving symptoms. Brisk capillary refill is a normal finding. The patient may see “stars” early on in decreased blood flow states.

Question 26

In which situations would the use of Methergine or prostaglandin be contraindicated even if the patient was experiencing a postpartum significant bleed? (Select all that apply.)

a. Patient has delivered twin pregnancies.
b. Patient’s blood pressure postpartum is 180/90.
c. Patient has a history of asthma.
d. Patient has a mitral valve prolapse.
e. Patient is a grand multip.

Answer 26

Ans: B, C, D
Twin pregnancies successfully delivered and grand multiparity are not contraindications to the use of these medications. If a patient is hypertensive or has cardiovascular disease, these medications would not be used. If a patient has a history of asthma, prostaglandin medication would not be used.