7th Ed Murray: Ch 18 Post Partum Maternal Complications

1. Which statement by a postpartum patient indicates that further teaching regarding thrombus
formation is unnecessary?
a. "I'll keep my legs elevated with pillows."
b. "I'll sit in my rocking chair most of the time."
c. "I'll stay in bed for the first 3 days after my baby is born."
d. "I'll put my support stockings on every morning before rising."
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1. Which statement by a postpartum patient indicates that further teaching regarding thrombus
formation is unnecessary?
a. "I'll keep my legs elevated with pillows."
b. "I'll sit in my rocking chair most of the time."
c. "I'll stay in bed for the first 3 days after my baby is born."
d. "I'll put my support stockings on every morning before rising."
Venous congestion begins as soon as the patient stands up. The stockings should be applied
before she rises from the bed in the morning. The patient should avoid knee pillows because
they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent
position causes pooling of blood in the lower extremities. As soon as possible, the patient
should ambulate frequently.
If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing
fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal
of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will
be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30
minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.
3. A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a
4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The
nurse has the patient void and massages her fundus; however, the fundus remains difficult to
find and the rubra lochia remains heavy. Which action should the nurse take next?

a. Recheck vital signs.
b. Insert a Foley catheter.
c. Notify the health care provider.
d. Continue to massage the fundus.
Treatment of excessive bleeding requires the collaboration of the health care provider and
the nurses. Do not leave the patient alone. The nurse should call the clinician while a second
nurse rechecks the vital signs. The patient has voided successfully, therefore a Foley
catheter is not needed at this time. The uterine muscle can be overstimulated by massage,
leading to uterine atony and rebound hemorrhage.
Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations will
not be affected by uterine contraction. The fundus would be boggy with a clinical finding of
uterine atony. A hematoma would occur internally with swelling and discoloration. With an
infection of the uterus, there would be an odor to the lochia and systemic symptoms such as
fever and malaise.
A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction.
Delivering a 5-lb, 2-oz infant with outlet forceps would put this patient at risk for lacerations
due to the use of forceps. A 7-lb infant after an 8-hour labor is a normal labor progression.
Less than 3 hours is considered a rapid labor and can produce uterine muscle exhaustion. An
8-lb infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid
birth and may cause the uterine muscles failure to contract.
D&C allows examination of the uterine contents and removal of any retained placenta or
membranes. A hysterectomy is the removal of the uterus and is not indicated in this
situation. A laparoscopy is the insertion of an endoscope through the abdominal wall to
examine the peritoneal cavity and would also not be necessary at this juncture. A
laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.
This patient requires a D&C rather than a laparotomy.
10. Which nursing measure would be most appropriate to prevent thrombophlebitis in the
recovery period following a cesarean birth?

a. Limit the patient's oral intake of fluids for the first 24 hours.
b. Assist the patient in performing leg exercises every 2 hours.
c. Ambulate the patient as soon as her vital signs are stable.
d. Roll a bath blanket and place it firmly behind the patient's knees.
Leg exercises promote venous blood flow and prevent venous stasis while the patient is still
on bed rest. Limiting oral intake will produce hemoconcentration, which may lead to
thrombophlebitis. The patient may not have full return of leg movements, and ambulating at
this time is contraindicated. The blanket behind the knees will cause pressure and decrease
venous blood flow.
11. Which temperature indicates the presence of postpartum infection? a. 37.5°C (99.6°F) in the first 48 hours b. 37.7°C (100°F) for 2 days postpartum c. 38°C (100.4°F) in the first 24 hours d. 38.2°C (100.8°F) on the second and third postpartum daysANS: D A temperature elevation of greater than 38°C (100.4°F) on two postpartum days, not including the first 24 hours, signifies infection. 37.5°C (99.6°F) in the first 48 hours is an expected finding due to dehydration. To be classified as an infection, the temperature needs to be greater than 38°C (100.4°F). It is anticipated that women have an elevated temperature the first 24 hours after delivery.12. A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates a. possible infection. b. normal WBC limit. c. serious infection. d. suspicion of a sexually transmitted disease.ANS: A A WBC count in the upper ranges of normal (20,000 to 30,000 cells/mm3 ) may indicate an infection. An elevated WBC count is anticipated but becomes a concern as it hits the upper range. An elevated WBC count may be an indication of different types of infection.13. The patient who is being treated for endometritis is placed in the Fowler position because this position a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.ANS: B Lochia and infectious material are eliminated by gravity drainage. The Fowler position may not be the position of comfort, but it does allow for drainage. Good hygiene practice aids in preventing the spread of infection to the urinary tract. This position aids in the drainage of lochia and infectious material.14. Nursing measures that help prevent postpartum urinary tract infection include a. forcing fluids to at least 3000 mL/day. b. promoting bed rest for 12 hours after birth. c. encouraging the intake of grapefruit juice and carbonated beverages. d. discouraging voiding until the sensation of a full bladder is present.ANS: A Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products. The patient should be encouraged to ambulate early. Drinks that acidify urine also inhibit bacterial growth. These include apricot, plum, prune, and cranberry juice. Grapefruit juice and soda should be avoided as they increase urine alkalinity. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The patient needs to be encouraged to void frequently.15. Which measure may prevent mastitis in a breastfeeding patient? a. Wearing a tight-fitting bra. b. Applying ice packs prior to feeding. c. Initiating early and frequent feedings. d. Nursing the infant for 5 minutes on each breast.ANS: C Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the milk. A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.16. A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? a. Organisms will be inactivated by gastric acid. b. Organisms that cause mastitis are not passed through the milk. c. The infant is not susceptible to the organisms that cause mastitis. d. The infant is protected from infection by immunoglobulins in the breast milk.ANS: B The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections; however, this infection is in the breast tissue and is not excreted in the breast milk. The patient is just producing the immunoglobulin from this infection, so it is not available for the infant.17. The nurse suspecting a uterine infection in a postpartum patient should assess the a. episiotomy site. b. odor of the lochia. c. abdomen for distention. d. pulse and blood pressure.ANS: B An abnormal odor of the lochia indicates infection in the uterus. The infection may move to the episiotomy site if proper hygiene is not followed. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and will be more specific.18. Following a difficult vaginal birth of a singleton pregnancy, the patient starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft and displaced laterally from midline. Vital signs are 37.6°C (99.8°F), pulse 90 beats/minute, respirations 20 breaths per minute, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated? a. Oxytocin (Pitocin) to be administered in a piggyback solution b. Administration of methylergonovine (Methergine) c. Administration of prostaglandin analog d. Increase in parenteral fluidsANS: C Prostaglandin analogs can be administered intramuscularly to stop uterine bleeding. Although Pitocin may be indicated in an attempt to stop uterine bleeding, it is not administered in a piggyback solution. Methergine is contraindicated in the presence of hypertension. Increasing fluids will not stop uterine bleeding.19. Following a vaginal birth, a patient has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this diagnosis? a. Decrease in blood pressure, with an increase in pulse pressure b. Compensatory response of tachycardia and decreased pulse pressure c. Decrease in heart rate and an increase in respiratory effort d. Flushed skinANS: B Clinical signs consistent with the early stages of hypovolemic shock include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color.20. A patient has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The patient now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to a. evaluate intake and output of the past 12 hours following birth. b. initiate a rapid response intervention. c. obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs). d. reposition the patient and reassess in 15 minutes. Initiate frequent vital sign assessments.ANS: B Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent patient history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the patient's complaints of difficulty breathing suggest that the patient is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the patient can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the patient, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.21. A postpartum patient has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen? a. Fresh fruits b. Milk c. Lentils d. SodaANS: C Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.22. To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should frequently assess a. temperature. b. lochial flow. c. fundal height. d. breath sounds.ANS: D Pulmonary edema is a potential adverse effect of carboprost tromethamine (Hemabate). Auscultation of breath sounds will identify pulmonary edema; temperature, lochial flow, and fundal height are not affected by this medication.23. If the nurse suspects a complication of a low forceps birth labor, she should immediately a. administer a strong oral analgesic. b. assess the perineal and vaginal areas. c. assess the position of the uterine fundus. d. review the labor record for duration of second stage.ANS: B A low forceps birth may result in significant vaginal trauma. Assessment will provide information on the extent of trauma of the perineum and vagina. Administering an analgesic may interfere with obtaining an accurate assessment of the problem, assessing the position of the uterine fundus will not provide any information on vaginal or perineal trauma, and reviewing the labor record may support the suspicion that trauma has occurred but will not identify extent of trauma.24. Prior to ambulating the patient whose admission hemoglobin level was 10.2 g/dL to the bathroom, the nurse should a. request repeat hemoglobin and hematocrit. b. assess the resting pulse rate. c. dangle her on the side of the bed. d. administer the ordered oral analgesic.ANS: C Patients with a low hemoglobin level prior to birth will most likely have a drop in the hemoglobin level following birth. A low hemoglobin level will result in dizziness and place the patient at risk for fainting when first ambulating. Having the patient sit on the side of the bed and dangle her legs prior to standing will allow for the blood pressure to stabilize and prevent fainting. Requesting additional labs will delay ambulation at a time when the patient needs to empty her bladder, assessing the resting pulse rate will not provide any information about the effect of ambulation on her cardiovascular system, and administering an ordered oral analgesic may contribute to feelings of faintness.25. If a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred a. on the first postpartum day. b. during recovery phase of labor. c. during the third stage of labor. d. on the second postpartum day.ANS: D A late postpartum hemorrhage occurs after the first 24 hours and up to 12 weeks after birth. The first postpartum day, during the recovery phase, and during the third stage are all within the first 24 hours after birth and would be classified as early postpartum hemorrhage.26. Which patient data received during report should the nurse recognize as being at risk for postpartum complications? a. Gravida 5, para 5 b. Labor duration of 4 hours c. Infant weight greater than 3800 g d. Epidural anesthesia for labor and birthANS: A Multiparity (five or more deliveries) is a risk factor for postpartum uterine atony and hemorrhage. A labor duration of 4 hours is not a risk factor because it is not a precipitate labor and birth (less than 3 hours), infant weight of 3800 g is not a risk factor because the infant is not macrosomic, and epidural anesthesia is not a risk factor because epidural anesthesia does not affect uterine contractions.27. Before administering methylergonovine (Methergine), the nurse checks the a. color of the lochia. b. blood pressure. c. location of the fundus. d. last administration of analgesics.ANS: B Methylergonovine (Methergine) elevates the blood pressure and should not be given to a woman who is hypertensive. The color of the lochia, location of the fundus, and analgesics are not related to the administration of or contraindicated to this medication.28. To evaluate the desired response of methylergonovine (Methergine), the nurse would assess the patient's a. uterine tone. b. pain level. c. blood pressure. d. last voiding.ANS: A Methylergonovine (Methergine) simulates sustained contraction of the uterus as evidenced by the tone of the uterus. The pain level, blood pressure, and voiding patterns are not related to the effectiveness of the medication.29. As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration? a. Fundus firm at the umbilicus b. Pulse of 90 bpm, blood pressure of 110/78 mm Hg c. Bright red continuous trickle of blood from vagina d. Patient requested pain medication twice during last shiftANS: C Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red color of lochia; a firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being medicated twice in one shift are common findings in the postpartum patient.30. The nurse observes the patient as she ambulates to the bathroom. Which clinical finding might indicate development of a DVT (deep vein thrombosis)? a. Slow gait b. Shuffling gait c. Stiffness of right leg d. Leans on husband for supportANS: C Deep vein thrombosis may cause pain on ambulation and stiffness of the affected leg. A slow gait, shuffling gait, and needing ambulatory support are common observations of the postpartum patient because of weakness and discomfort of the perineum.31. If a DVT (deep vein thrombosis) is suspected, the nurse should a. perform a Homans sign on the affected leg. b. dorsiflex the foot of the affected leg. c. palpate the affected leg for edema and pain. d. place the patient on bed rest, with the affected leg elevated.ANS: D Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.32. If the nurse suspects a pulmonary embolism in the patient who suddenly complains of chest pain, she or he should immediately a. assess for abnormal breath sounds. b. apply O2 via tight face mask at 8 to 10 L/minute. c. position the patient in a supine position with the head of the bed flat. d. monitor pulse oximetry for decreased oxygen saturation.ANS: B Administration of oxygen will increase oxygen saturation and decrease hypoxia; assessing breath sounds and monitoring pulse oximetry provide assessment data but do not correct the problem. A supine position with the head of the bed flat is incorrect because the head of the bed should be elevated to facilitate respiratory function.33. To prevent infection of the reproductive tract, the nurse should instruct the patient to a. change the peripad once per shift. b. cleanse the perineum from front to back. c. perform pericare at least twice during the shift. d. increase fluid intake to 2500 to 3000 mL/day.ANS: B Lack of knowledge of hygiene measures increases the risk of postpartum infection. Wiping the perineum from front to back prevents introduction of infection into the reproductive tract from the anal area. Changing the peripad once per shift and performing pericare twice in a shift are incorrect because these interventions should be done at every voiding or bowel elimination, and increasing fluid intake does not prevent infection of the reproductive tract.34. The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse's priority action? a. Massage the fundus of the uterus. b. Assist the patient out of bed to void. c. Increase the infusion of oxytocin (Pitocin). d. Ask another nurse to bring in a straight catheter tray.ANS: A If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment, while the other hand gently but firmly massages the fundus in a circular motion. Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. If the uterus does not remain contracted as a result of uterine massage or if the fundus is displaced, the bladder may be distended. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate or catheterize her to correct uterine atony caused by bladder distention. Note the urine output. When the fundus is boggy, begin uterine massage. Check the woman's bladder for distention and have her empty it if necessary. If she is not able to void and the bladder is distended, catheterize the patient. Weigh blood-soaked pads.35. Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.) a. Insufficient emptying b. Feeding every 2 hours c. Supplementing feedings d. Blisters on both nipples e. Alternating breastfeeding positionsANS: A, C, D Mastitis may develop because of stasis of milk, inadequate emptying of the breast, skipped feedings, and introduction of bacteria through injured areas of the nipple. Feeding every 2 hours and alternating breastfeeding positions are both interventions that promote emptying of the breasts and support successful breastfeeding.36. The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include which of the following? (Select all that apply.) a. Anemia b. Dehydration c. Exhaustion d. Postpartum infection e. Failure to attach to her infantANS: A, C, D, E Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated. Exhaustion is common after hemorrhage. It may take the new patient weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and the attachment processes. The patient is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection. The excessive blood loss that this patient has experienced is likely to lead to risk for infection rather than dehydration. It is important that all mothers be educated about adequate fluid intake after birth.