Chapter 28: Postpartum Maternal Complications My Nursing Test Banks

Chapter 28: Postpartum Maternal Complications

MULTIPLE CHOICE

1. Which statement by a postpartum client indicates that further teaching is not needed regarding thrombus formation?

a.

Ill keep my legs elevated with pillows.

b.

Ill sit in my rocking chair most of the time.

c.

Ill stay in bed for the first 3 days after my baby is born.

d.

Ill put my support stockings on every morning before rising.

ANS: D

Venous congestion begins as soon as the client stands up. The stockings should be applied before she rises from the bed in the morning. The client 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 client should ambulate frequently.

PTS: 1 DIF: Cognitive Level: Application REF: 607

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

2. The nurse knows that late postpartum hemorrhage can be prevented by:

a.

manually removing the placenta.

b.

inspecting the placenta after birth.

c.

administering broad-spectrum antibiotics.

d.

pulling on the umbilical cord to hasten the birth of the placenta.

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Application REF: 602

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

3. A multiparous client 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 client void and massages her fundus, but 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.

ANS: C

Treatment of excessive bleeding requires the collaboration of the health care provider and the nurses. Do not leave the client alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The client has voided successfully, so a Foley catheter is not needed at this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.

PTS: 1 DIF: Cognitive Level: Application REF: 604

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

4. Early postpartum hemorrhage is defined as a blood loss greater than:

a.

500 mL within 24 hours after a vaginal birth.

b.

750 mL within 24 hours after a vaginal birth.

c.

1000 mL within 48 hours after a cesarean birth.

d.

1500 mL within 48 hours after a cesarean birth.

ANS: B

The average amount of bleeding after a vaginal birth is 500 mL. Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean averages 1000 mL. Late postpartum hemorrhage is 48 hours and later.

PTS: 1 DIF: Cognitive Level: Understanding REF: 598

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

5. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:

a.

uterine atony.

b.

perineal hematoma.

c.

infection of the uterus.

d.

lacerations of the genital tract.

ANS: D

Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus would not be firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus, there would be an odor to the lochia and systemic symptoms such as fever and malaise.

PTS: 1 DIF: Cognitive Level: Understanding REF: 601

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

6. A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a(n):

a.

5-lb, 2-oz infant with outlet forceps.

b.

6.5-lb infant after a 2-hour labor.

c.

7-lb infant after an 8-hour labor.

d.

8-lb infant after a 12-hour labor.

ANS: B

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 client at risk for lacerations because of the forceps. A 7-lb infant after an 8-hour labor is a normal labor progression. Less than 3 hours is rapid 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 can cause the uterine muscles not to contract.

PTS: 1 DIF: Cognitive Level: Understanding REF: 605

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

7. Which instruction should be included in the discharge teaching plan to assist the client in recognizing early signs of complications?

a.

Palpate the fundus daily to ensure that it is soft.

b.

Report any decrease in the amount of brownish red lochia.

c.

The passage of clots as large as an orange can be expected.

d.

Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding.

ANS: D

An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. The lochia should decrease in amount. Large clots after discharge are a sign of complications and should be reported.

PTS: 1 DIF: Cognitive Level: Application REF: 599

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

8. The nurse should expect medical intervention for subinvolution to include:

a.

oral fluids to 3000 mL/day.

b.

intravenous fluid and blood replacement.

c.

oxytocin intravenous infusion for 8 hours.

d.

oral methylergonovine maleate (Methergine) for 48 hours.

ANS: D

Methergine provides long-sustained contraction of the uterus. There is no correlation between dehydration and subinvolution. There is no indication that excessive blood loss has occurred. Oxytocin provides intermittent contractions.

PTS: 1 DIF: Cognitive Level: Understanding REF: 605

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

9. If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

a.

Hysterectomy

b.

Laparoscopy

c.

Laparotomy

d.

Dilation and curettage (D&C)

ANS: D

D&C allows examination of the uterine contents and removal of any retained placenta or membranes. Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus. Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.

PTS: 1 DIF: Cognitive Level: Understanding REF: 602

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

10. A sign of thrombophlebitis is:

a.

visible varicose veins.

b.

positive Homans sign.

c.

pedal edema in the affected leg.

d.

local tenderness, heat, and swelling.

ANS: D

Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the client to thrombophlebitis, but are not a sign. A positive Homans sign is indicative of deep vein thrombosis (DVT).

PTS: 1 DIF: Cognitive Level: Understanding REF: 606

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth?

a.

Limit the clients oral intake of fluids for the first 24 hours.

b.

Assist the client in performing leg exercises every 2 hours.

c.

Ambulate the client as soon as her vital signs are stable.

d.

Roll a bath blanket and place it firmly behind the clients knees.

ANS: B

Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bed rest. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The client may not have full return of leg movements, and ambulating is contraindicated. The blanket behind the knees will cause pressure and decrease venous blood flow.

PTS: 1 DIF: Cognitive Level: Application REF: 607

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

12. Which temperature indicates the presence of postpartum infection?

a.

99.6 F in the first 48 hours

b.

100 F for 2 days postpartum

c.

100.4 F in the first 24 hours

d.

100.8 F on the second and third postpartum days

ANS: D

A temperature elevation to greater than 100.4 F on two postpartum days, not including the first 24 hours, indicates infection. 99.6 F in the first 48 hours is an expected finding because of dehydration. To be classified as an infection, the temperature needs to be greater than 100.4 F. It is anticipated that women have an elevated temperature the first 24 hours.

PTS: 1 DIF: Cognitive Level: Understanding REF: 609

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. 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.

PTS: 1 DIF: Cognitive Level: Understanding REF: 614

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

14. The client who is being treated for endometritis is placed in the Fowler position because it:

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 611

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

15. 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 orange, grapefruit, or apple juice.

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 client should be encouraged to ambulate early. Juices such as cranberry juice can discourage bacterial growth. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The client needs to be encouraged to void frequently.

PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

16. Which measure may prevent mastitis in a breastfeeding client?

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.

PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

17. A client 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 to 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 infants 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 client is just producing the immunoglobulin from this infection, so it is not available for the infant.

PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

18. The nurse expecting a uterine infection in a postpartum client 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.

PTS: 1 DIF: Cognitive Level: Application REF: 615

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

19. Following a difficult vaginal birth of a singleton pregnancy, the client 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 99.8 F, pulse 90 beats/min, respirations 20 breaths/min, 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 analogue

d.

Increase in parenteral fluids

ANS: C

Prostaglandin analogues 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 600

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity/Pharmacologic Parental Therapies

20. Following a vaginal birth, a client has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this clinical 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 skin

ANS: B

Clinical signs consistent with the beginning of hypovolemic shock include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color.

PTS: 1 DIF: Cognitive Level: Application REF: 602

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

21. A client 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 client 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 client 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 client history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the clients complaints of difficulty breathing suggest that the client is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the client can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the client, 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 604

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

22. A postpartum client 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.

Soda

ANS: 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.

PTS: 1 DIF: Cognitive Level: Application REF: 608

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

23. The nurse recognizes that infection may be present in her postpartum client when the client exhibits a temperature of:

a.

100.0 F during the first 36 hours postpartum.

b.

100.8 F twice in the first 24 hours postpartum.

c.

99.6 F on the first postpartum day and 100.4 on the second.

d.

100.4 F on the second postpartum day and 100.8 F on the fourth.

ANS: D

The definition of puerperal infection is a temperature of 100.4 F or higher after the first 24 hours, occurring on at least two of the first 10 days following childbirth. 100.8 F in the first 24 hours, 100.0 F in the first 36 hours, and 99.6 F on the first day and 100.4 F on the second day do not meet the definition of puerperal infection.

PTS: 1 DIF: Cognitive Level: Analysis REF: 609

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

24. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 601

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic integrity

25. Which labor and birth information on the client would suggest an increased risk for hemorrhage?

a.

Precipitous birth after a 12-hour labor

b.

Cesarean birth of an infant weighing 8 lb, 4 oz

c.

Vaginal birth of 7-lb infant after a 2-hour labor

d.

Vaginal birth of 6-lb infant after a 7-hour labor

ANS: C

Precipitous labor (<3 hours) is a risk for postpartum hemorrhage; precipitous birth following a normal duration of labor, cesarean birth of an 8-lb, 4-oz infant, and vaginal birth of a 6-lb infant after a 7-hour labor do not increase the risk of postpartum hemorrhage.

PTS: 1 DIF: Cognitive Level: Analysis REF: 598

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

26. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 604

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

27. Prior to ambulating the client to the bathroom whose admission hemoglobin level was 10.2 g/dL, 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

Clients 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 client at risk for fainting when first ambulating. Dangling the client on the side of the bed 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 client 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.

PTS: 1 DIF: Cognitive Level: Application REF: 604

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic integrity

28. If a late postpartum hemorrhage is documented on a client 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 612

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

29. Which client data received during report should the nurse recognize as being a postpartum risk factor?

a.

Gravida 5, para 5

b.

Labor duration of 4 hours

c.

Infant weight greater than 3800 g

d.

Epidural anesthesia for labor and birth

ANS: 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.

PTS: 1 DIF: Cognitive Level: Application REF: 599

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

30. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 600

OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

31. To evaluate the desired response of methylergonovine (Methergine), the nurse would assess the clients:

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.

PTS: 1 DIF: Cognitive Level: Application REF: 600

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

32. Which data collected during your assessment may indicate a vaginal wall hematoma?

a.

Firm uterus at U-1

b.

Pulse rate of 110 bpm

c.

Moderate lochia

d.

Soreness of perineum

ANS: B

Trauma to the vaginal area from a forceps birth may result in significant blood loss from hematomas or lacerations. Tachycardia is an early sign of compensation for excessive blood loss. If vital signs suggest hemorrhage but excessive bleeding is not obvious, the cause may be concealed bleeding and the formation of a hematoma; a firm fundus, moderate lochia, and soreness of the perineum are normal findings.

PTS: 1 DIF: Cognitive Level: Analysis REF: 601

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

33. As you receive a report, which assessment finding should you recognize as indicative 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.

Client requested pain medication twice during last shift

ANS: 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 client.

PTS: 1 DIF: Cognitive Level: Analysis REF: 601

OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

34. Which observation of your client as she ambulates could indicate development of a DVT (deep vein thrombosis)?

a.

Slow gait

b.

Shuffling gait

c.

Stiffness of right leg

d.

Leans on husband for support

ANS: 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 client because of weakness and discomfort of the perineum.

PTS: 1 DIF: Cognitive Level: Analysis REF: 607

OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

35. 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 client 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.

PTS: 1 DIF: Cognitive Level: Application REF: 607

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

36. If the nurse suspects a pulmonary embolism in the client 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/min.

c.

position the client 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.

PTS: 1 DIF: Cognitive Level: Application REF: 609

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

37. To prevent infection of the reproductive tract, the nurse should instruct the client 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.

PTS: 1 DIF: Cognitive Level: Application REF: 610

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

38. For the client diagnosed with endometritis, the nurse recognizes that the client should be positioned in the:

a.

prone position.

b.

side-lying position.

c.

Fowler position.

d.

supine position with the head flat.

ANS: C

The Fowler position promotes drainage of lochia from the reproductive tract. The prone position, side-lying position, and supine position do not promote drainage from the reproductive tract.

PTS: 1 DIF: Cognitive Level: Application REF: 610

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

39. To prevent infection of the urinary tract, the nurse should instruct the client to:

a.

include soft drinks in the total fluid intake.

b.

drink grapefruit juice several times a day.

c.

perform pericare at least twice during a shift.

d.

increase fluid intake to 2500 to 3000 mL/day.

ANS: D

Drinking 2500 to 3000 mL of fluid each day will dilute the bacterial count and flush the infection from the bladder. Ingesting soft drinks and grapefruit juice increase urine alkalinity, which provides a medium for bacterial growth; pericare performed twice during a shift is not frequent enough to remove bacteria, and pericare should be done at each voiding or bowel movement.

PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

40. What data in the clients history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?

a.

Teenage depression episode

b.

Unexpected operative birth

c.

Ambivalence during the first trimester

d.

Second pregnancy in a 3-year period

ANS: A

A personal history of depression is a risk factor for postpartum depression. An operative birth, ambivalence during the first trimester, and two pregnancies in 3 years are not risk factors for postpartum depression.

PTS: 1 DIF: Cognitive Level: Analysis REF: 614

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Psychosocial integrity

41. 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 nurses 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 womans bladder for distention and have her empty it if necessary. If she is not able to void and the bladder is distended, catheterize the woman. Weigh blood-soaked pads.

PTS: 1 DIF: Cognitive Level: Applying REF: 599, 600

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

42. For the patient experiencing a postpartum hemorrhage, the health care provider prescribes methylergonovine (Methergine). What assessment must the nurse perform prior to administering this medication?

a.

Heart rate

b.

Temperature

c.

Blood pressure

d.

Respiratory rate

ANS: C

Methylergonovine (Methergine) may be given intramuscularly but it elevates blood pressure and should not be given to a woman who is hypertensive.

PTS: 1 DIF: Cognitive Level: Understanding REF: 600

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE

43. 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 positions

ANS: 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 612

OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Safe Effective Care Environment/Management of Care

44. 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 infant

ANS: 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 client weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and the attachment processes. The client is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection. The excessive blood loss that this client 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.

PTS: 1 DIF: Cognitive Level: Application REF: 616

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

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