Chapter 34: Postpartum Complications

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Chapter 35: Postpartum Complications (page references are from the 9th edition text)

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

A

A. Correct: Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage.
B. Incorrect: Uterine inversion may lead to hemorrhage, but it is not the most likely source of this client's bleeding. Furthermore, if the woman was experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus.
C. Incorrect: A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding.
D. Incorrect: 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.

p. 976

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

B

A. Incorrect: Although this may be a necessary intervention, the initial intervention would be fundal massage.
B. Correct: The initial management of excessive postpartum bleeding is firm massage of the uterine fundus.
C. Incorrect: The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention would be to assess the uterus.
D. Incorrect: After uterine massage, the nurse may want to catheterize the client to eliminate any bladder distension that may be preventing the uterus from contracting properly.

p. 979

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by:

A. Subinvolution of the placental site
B. Defective vascularity of the decidua
C. Cervical lacerations
D. Coagulation disorders

A

A. Correct: Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments.
B. Incorrect: Although this condition may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.
C. Incorrect: Although this condition may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.
D. Incorrect: Although this condition may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

p. 977

What woman is at greatest risk for early postpartum hemorrhage?

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

B

A. Incorrect: Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.
B. Correct: Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony.
C. Incorrect: Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.
D. Incorrect: Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.

p. 976

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

C

A. Incorrect: This intervention is appropriate. However, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of PPH.
B. Incorrect: This intervention is appropriate. However, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of PPH.
C. Correct: The initial management of excessive postpartum bleeding is firm massage of the uterine fundus.
D. Incorrect: This intervention is appropriate. However, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of PPH.

p. 979

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

D

A. Incorrect: The assessment of the buccal mucosa for cyanosis can be subjective in nature.
B. Incorrect: The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock.
C. Incorrect: Hemorrhagic shock is associated with lethargy, not restlessness.
D. Correct: 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.

p. 983

The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy?

A. Large doses of vitamin C during pregnancy
B. Prophylactic antibiotics
C. Strict aseptic technique, including handwashing, by all health care personnel
D. Limited protein and fat intake

C

A. Incorrect: Good nutrition to control anemia is a preventive measure. Increased iron intake would assist in preventing anemia.
B. Incorrect: Antibiotics may be given to manage infections; they are not a cost-effective measure to prevent postpartum infection.
C. Correct: Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is very important and the least expensive measure to prevent infection.
D. Incorrect: Good nutrition to control anemia is a preventive measure. Limiting protein and fat intake will not help prevent anemia or prevent infection.

p. 988

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

D

A. Incorrect: Fatigue would be a late finding associated with infection.
B. Incorrect: Pain with voiding may indicate a UTI, but it is not typically one of the earlier symptoms of infection.
C. Incorrect: Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.
D. Correct: 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.

p. 987

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

B

A. Incorrect: 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.
B. Correct: Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples.
C. Incorrect: Wearing a nipple shield does not prevent mastitis.
D. Incorrect: 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.

p. 989

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?

A. Bleeding time of 10 minutes
B. Presence of fibrin split products
C. Thrombocytopenia
D. Hyperfibrinogenemia

B

A. Incorrect: Bleeding time in DIC is normal.
B. Correct: Degradation of fibrin leads to the accumulation of fibrin split products in the blood.
C. Incorrect: Low platelets may occur with but are not indicative of DIC, because they may result from other coagulopathies.
D. Incorrect: Hypofibrinogenemia would occur with DIC.

p. 985

In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:

A. Disseminated intravascular coagulation
B. Amniotic fluid embolism
C. Hemorrhage
D. HELLP syndrome

A

A. Correct: The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman's arm. Excessive bleeding may occur from the site of a slight trauma, such as venipuncture sites.
B. Incorrect: These symptoms are not associated with AFE, nor is AFE a bleeding disorder.
C. Incorrect: Hemorrhage occurs for a variety of reasons in the PP client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself.
D. Incorrect: HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

p. 984

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?

A. Administration of blood
B. Preparation of the client for invasive hemodynamic monitoring
C. Restriction of intravascular fluids
D. Administration of steroids

A

A. Correct: Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters.
B. Incorrect: Central monitoring would not be ordered initially in a client with DIC, because this can contribute to more areas of bleeding.
C. Incorrect: Management of DIC would include volume replacement, not volume restriction.
D. Incorrect: Steroids are not indicated for the management of DIC.

p. 985

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage. 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.

D

A. Incorrect: Unfortunately, PPH can occur with little warning and often is recognized only after the mother has profound symptoms.
B. Incorrect: Traditionally, a 500 ml blood loss after a vaginal birth and a 1000 ml blood loss after a cesarean birth constitute PPH.
C. Incorrect: Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.
D. Correct: Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH.

p. 975

Nurses should first look for the most common cause of PPH, _____, by _____.

A. Lacerations of the genital tract; checking for the source of blood
B. Uterine atony; evaluating the contractility of the uterus
C. Inversion of the uterus; feeling for a smooth mass through the dilated cervix
D. Retained placenta; noting the type of bleeding

B

A. Incorrect: The leading cause of PPH is uterine atony, which complicates one in 20 births. The uterus is overstretched and contracts poorly after the birth.
B. Correct: The leading cause of PPH is uterine atony, which complicates one in 20 births. The uterus is overstretched and contracts poorly after the birth.
C. Incorrect: The leading cause of PPH is uterine atony, which complicates one in 20 births. The uterus is overstretched and contracts poorly after the birth.
D. Incorrect: The leading cause of PPH is uterine atony, which complicates one in 20 births. The uterus is overstretched and contracts poorly after the birth.

p. 976

A woman who has recently given birth complains of pain and tenderness in her leg. Upon 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

C

A. Incorrect: Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound is a common, noninvasive way to confirm the diagnosis.
B. Incorrect: Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound is a common, noninvasive way to confirm the diagnosis.
C. Correct: Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.
D. Incorrect: Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound is a common, noninvasive way to confirm the diagnosis.

p. 985

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

A

A. Correct: Inversion of the uterus and hypovolemic shock are considered medical emergencies.
B. Incorrect: Although this is a serious condition, it is not necessarily a medical emergency that requires immediate treatment.
C. Incorrect: Although this is a serious condition, it is not necessarily a medical emergency that requires immediate treatment.
D. Incorrect: Although this is a serious condition, it is not necessarily a medical emergency that requires immediate treatment.

pp. 980, 983

What infection is contracted mostly by first-time mothers who are breastfeeding?

A. Endometritis
B. Wound infections
C. Mastitis
D. Urinary tract infections

C

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

p. 988

It is important for the perinatal nurse to be knowledgeable regarding conditions of abnormal adherence of the placenta. This occurs when the zygote implants in an area of defective endometrium and results in little to no zone separation between the placenta and decidua. Which classification of separation is not recognized as an abnormal adherence pattern?

A. Placenta accreta
B. Placenta increta
C. Placenta percreta
D. Placenta abruptio

D

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

pp. 822, 977

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 postdelivery 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
B. Factor VIII and vWf
C. Desmopressin
D. Hemabate

C

A. Incorrect: Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer.
B. Incorrect: 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.
C. Correct: 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.
D. Incorrect: 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.

pp. 981, 984

Medications used to manage postpartum hemorrhage include (choose all that apply):

A. Pitocin
B. Methergine
C. Terbutaline
D. Hemabate
E. Magnesium sulfate

A, B, D

Correct: These medications are all used to manage PPH.

Incorrect: These medications are tocolytics; relaxation of the uterus causes or worsens PPH.

p. 981

____________________ is the most common postpartum infection.

Endometritis

p. 987

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