Chapter 24: Postpartum complications

Question 1

1. The perinatal nurse’s assessment while caring for a patient in the immediate postpartum period reveals that the patient is experiencing profuse bleeding. What is the most likely etiology for her bleeding?
   a. Uterine atony
   b. Uterine inversion
   c. Vaginal hematoma
   d. Vaginal laceration

Answer 1

ANS: A
Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient’s bleeding. Furthermore, if the patient were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

Question 2

2. Which is a primary nursing responsibility when caring for a patient experiencing an obstetrical hemorrhage associated with uterine atony?
   a. Establish venous access.
   b. Perform fundal massage.
   c. Prepare the patient for surgical intervention.
   d. Catheterize the bladder.

Answer 2

ANS: B
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The patient may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the patient to eliminate any bladder distension that may be preventing the uterus from contracting properly.

Question 3

3. A perinatal nurse caring for the postpartum patient understands that late postpartum hemorrhage (PPH) is most likely caused by
   a. subinvolution of the placental site.
   b. defective vascularity of the decidua.
   c. cervical lacerations.
   d. coagulation disorders.

Answer 3

ANS: A
Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.

Question 4

4. Which patient is at greatest risk for early postpartum hemorrhage (PPH)?
   a. A primiparous patient being prepared for an emergency Caesarean birth for fetal
   distress
   b. A patient with severe pre-eclampsia on magnesium sulphate whose labour is
   being induced
   c. A multiparous patient with an 8-hour labour
   d. A primigravida in spontaneous labour with preterm twins

Answer 4

ANS: B
Magnesium sulphate administration during labour poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous patient being prepared for an emergency Caesarean birth, the multiparous patient with 8-hour labour, and the primigravida in spontaneous labour are not at risk for early PPH.

Question 5

5. What is the initial priority nursing intervention when a nurse observes profuse postpartum bleeding?
   a. Call the patient’s primary health care provider.
   b. Administer the standing order for an oxytocic.
   c. Palpate the uterus and massage it if it is boggy.
   d. Assess maternal blood pressure (BP) and pulse for signs of hypovolemic shock.

Answer 5

ANS: C
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage.

Question 6

6. What is the most objective and least invasive assessment of adequate organ perfusion and oxygenation when caring for a postpartum patient experiencing hemorrhagic shock?
   a. Absence of cyanosis in the buccal mucosa
   b. Cool, dry skin
   c. Diminished restlessness
   d. Urinary output of at least 30 mL/hr

Answer 6

ANS: D
Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective in nature. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

Question 7

7. Which is one of the first symptoms of puerperal infection to assess for in the postpartum patient?
   a. Fatigue continuing for longer than 1 week
   b. Pain with voiding
   c. Profuse vaginal bleeding with ambulation
   d. Temperature of 38.6C

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. A temperature greater than 38C warrants further investigation for a puerperal infection. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection

Question 8

8. The perinatal nurse assisting with establishing lactation is aware that which action can minimize acute mastitis?
   a. Washing the nipples and breasts with mild soap and water once a day
   b. Using proper breastfeeding techniques
   c. Wearing a nipple shield for the first few days of breastfeeding
   d. Wearing a supportive bra 24 hours a day

Answer 8

ANS: B
Almost all instances of acute mastitis can be avoided by using proper breastfeeding technique to prevent cracked nipples. Washing the nipples and breasts daily is no longer indicated. In fact, this can cause tissue dryness and irritation, which can lead to tissue breakdown and infection. Wearing a nipple shield does not prevent mastitis. Wearing a supportive bra 24 hours a day may contribute to mastitis, especially if an underwire bra is worn, because it may put pressure on the upper, outer area of the breast, contributing to blocked ducts and mastitis.

Question 9

9. Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance
   a. PPH is easy to recognize early; after all, the patient is bleeding.
   b. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL
   after Caesarean birth to define the condition as PPH.
   c. if anything, nurses and doctors tend to overestimate the amount of blood loss.
   d. traditionally PPH has been classified as primary or secondary.

Answer 9

ANS: D
Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately, PPH can occur with little warning and often is recognized only after the mother has profound symptoms. Traditionally, a 500-mL blood loss after a vaginal birth and a 1000-mL blood loss after a Caesarean birth constitute PPH. Health care personnel tend to underestimate blood loss by 33% to 55% in their subjective observations.

Question 10

10. A patient who has recently given birth states they have pain and tenderness in their leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. What should the nurse suspect, and then what should the nurse implement to confirm the diagnosis?
    a. Disseminated intravascular coagulation; ask for laboratory tests.
    b. von Willebrand disease; note whether bleeding times have been extended.
    c. Thrombophlebitis; ask for ultrasound examination.
    d. Coagulopathies; draw blood for laboratory analysis.

Answer 10

ANS: C
Pain and tenderness in the extremities that show warmth, redness, and hardness likely indicate thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.

Question 11

11. What postpartum hemorrhage (PPH) conditions are considered medical emergencies that require immediate treatment?
    a. Inversion of the uterus and hypovolemic shock
    b. Hypotonic uterus and coagulopathies
    c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura
    d. Uterine atony and disseminated intravascular coagulation

Answer 11

ANS: A
Inversion of the uterus and hypovolemic shock are potentially life-threatening complications and are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that require immediate treatment.

Question 12

12. What infection is contracted mostly by mothers who are breastfeeding and usually occurs after the first postpartum week?
    a. Endometritis
    b. Wound infections
    c. Mastitis
    d. Urinary tract infections

Answer 12

ANS: C
Mastitis is infection in a breast, usually confined to a milk duct. Most patients who suffer this are breastfeeding and symptoms rarely appear before the end of the first postpartum week.

Question 13

13. What medication should the nurse expect to see ordered first for the patient with von Willebrand disease who experiences a postpartum hemorrhage?
    a. Cryoprecipitate
    b. Factor VIII and von Willebrand factor (vWf)
    c. Desmopressin
    d. Hemabate

Answer 13

ANS: C
Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, it would not be the first medication ordered for this patient. Treatment with plasma products such as factor VIII and vWf are an acceptable option for this patient. Because of the repeated exposure to donor blood products and possible viruses, however, this is not the initial treatment of choice. Although the administration of the prostaglandin Hemabate is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the patient who presents with a bleeding disorder.

Question 14

14. The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Many patients experience a perinatal mood disorder (PMD). Which statement regarding PMD is essential for the nurse to be aware of when attempting to formulate a nursing plan?
    a. PPD symptoms are consistently severe.
    b. This syndrome affects only new mothers.
    c. PPD can easily go undetected.
    d. Only mental health professionals should teach new parents about this condition.

Answer 14

ANS: C
PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with patients having both good and bad days. Both mothers and fathers should be screened. PPD may also affect new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all patients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if symptoms occur.

Question 15

15. A patient gave birth to a 4500 g baby 1 hour ago. When completing the patient’s 15-minute assessment, they tell a nurse that they “feels all wet underneath.” The nurse discovers that both pads are completely saturated and that the patient is lying in a 10 cm-diameter puddle of blood. What is the nurse’s first action?
    a. Call for help.
    b. Assess the fundus for firmness.
    c. Take their blood pressure.
    d. Check the perineum for lacerations.

Answer 15

ANS: B
Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Assessing blood pressure is an important assessment with a bleeding patient; however, the top priority is to control the bleeding. If bleeding continues in the presence of a firm fundus, lacerations may be the cause.

Question 16

16. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests
    a. uterine atony.
    b. lacerations of the genital tract.
    c. perineal hematoma.
    d. infection of the uterus.

Answer 16

ANS: B
Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm in the presence of uterine atony. A hematoma would develop internally. Swelling and discoloration would be noticeable; however, bright bleeding would not be. With an infection of the uterus there would be an odour to the lochia and systemic symptoms such as fever and malaise.

Question 17

17. What is one of the main concerns when a patient is diagnosed with postpartum depression (PPD)?
    a. They may have outbursts of anger.
    b. They may neglect their hygiene.
    c. They may harm their infant.
    d. They may lose interest in their partner.

Answer 17

ANS: C
Thoughts of harm to oneself or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger, hygiene neglect, and loss of interest in their partner are attributable to PPD, the major concern would be the potential to harm themselves or their infant.

Question 18

18. What should the nurse know to provide adequate postpartum care to the patient experiencing postpartum depression (PPD)?
    a. PPD means that the patient is experiencing the baby blues. In addition, she has a
    visit with a counsellor or psychologist.
    b. PPD is more common among older, White patients because they have higher
    expectations.
    c. PPD is distinguished by irritability and labile mood swings.
    d. PPD will disappear on its own without outside help.

Answer 18

ANS: C
PPD is also characterized by spontaneous crying long after the usual duration of the baby blues. PPD, is more serious and persistent than postpartum baby blues. It is more common among younger mothers and those with less education. Most patients need professional help, including pharmacological intervention, to get through PPD.

Question 19

19. To provide adequate postpartum care, a nurse should be aware that postpartum psychosis
    a. is more likely to occur in patients with more than two children.
    b. is rarely delusional and then is usually about someone trying to harm her (the
    mother).
    c. although serious, is not likely to need psychiatric hospitalization.
    d. may include bipolar disorder (formerly called “manic depression”).

Answer 19

ANS: D
Postpartum psychosis is commonly associated with the diagnosis of bipolar (or manic-depressive) disorder. Manic mood swings are possible. Once a patient has had one postpartum episode with psychotic features, there is a 30% to 50% likelihood of recurrence with each subsequent birth; therefore, it is not more likely to occur after the birth of a patient’s first child. Episodes of postpartum psychosis are typified by auditory or visual hallucinations and paranoid or grandiose delusions. Postpartum psychosis is a psychiatric emergency that requires hospitalization.

Question 20

20. With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the “baby blues” or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her in self-care activities to help prevent postpartum depression. What is the most accurate statement as related to these activities?
    a. Stay home and avoid outside activities to ensure adequate rest.
    b. Be certain that you are the only caregiver for your baby to facilitate infant
    attachment.
    c. Keep feelings of sadness and adjustment to your new role to yourself.
    d. Realize that this is a common occurrence that affects many patients.

Answer 20

ANS: D
Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of. As many as 80% of new mothers experience similar symptoms. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she not isolate herself at home during this time of role adjustment. Even if she is breastfeeding, other family members can participate in the infant’s care. If depression occurs, the symptoms can often interfere with mothering functions, and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be “superpatient.” A telephone call to the hospital warm line may provide reassurance about lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.

Question 21

21. A family is visiting two surviving triplets. The third triplet died 2 days ago. What action would indicate that the family had begun to grieve for the dead infant?
    a. They refer to the two live infants as twins.
    b. They ask about the dead triplet’s current status.
    c. They bring in play clothes for all three infants.
    d. They refer to the dead infant in the past tense.

Answer 21

ANS: D
Accepting that the infant is dead (in the past tense of the word) demonstrates acceptance of the reality and that the family has begun to grieve. Referring to the two live infants as twins, asking about the dead infant’s current status, and bringing clothing for all three infants all indicate that the parents are in denial.

Question 22

22. What is the basis for the most appropriate statement that the nurse can make to young bereaved parents?
    a. Indicating that the parents now have an angel in heaven.
    b. Expressing to the parents that the nurse understands how they feel.
    c. Pointing out to them that they are young and will have future opportunities to be
    parents.
    d. Expressing to the parents that you are sorry for their loss.

Answer 22

ANS: D
One of nurse’s most important goals is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment, such as “I’m sorry.” The initial impulse may be to reduce the sense of helplessness and to say or do something that one might think would reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. The statement “You’re young and can have other children” is not a therapeutic response for the nurse to make.

Question 23

23. What options for saying goodbye would the nurse want to discuss with a patient who is diagnosed with having a stillborn girl?
    a. The nurse shouldn’t discuss any options at this time; there is plenty of time after
    the baby is born.
    b. Ask the mother if she would like a picture taken of her baby after birth.
    c. Ask the patient if she would like to see and hold her baby after birth.
    d. Assist the family in deciding what funeral home is to be notified after the baby is
    born.

Answer 23

ANS: C
Mothers and fathers may find it helpful to see the newborn after birth. The parents’ wishes should be respected. While interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents, the initial intervention should be related directly to the parents’ wishes with regard to seeing or holding their dead infant. Altho ugh information regarding burial arrangements may be relevant, it is not the most appropriate option at this time and can be discussed after the infant is born.

Question 24

24. A patient experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). They state they are just fine and want to go home as soon as possible. While a nurse is assessing their responses to their loss, they tell you that they had purchased some baby things and had picked out a name. On the basis of your assessment of the responses, what nursing intervention would the nurse do first?
    a. Ready them for discharge.
    b. Notify pastoral care to offer them a blessing.
    c. Ask them if they would like to see what was obtained from their D&C.
    d. Ask them what name they had picked out for their baby.

Answer 24

ANS: D
One way of actualizing the loss is to allow parents to name the infant. The nurse should follow this patient’s cues and inquire about naming the infant. The patient is looking for an opportunity to express their feelings of loss. Although it may be therapeutic to offer religious support, the nurse should take this opportunity to offer support by allowing the patient to talk about their feelings. Asking the patient if they would like to see what was obtained from her D&C is completely inappropriate.

Question 25

25. A patient is diagnosed with having a stillborn. At first, they appear stunned by the news, cry a little, and then asks a nurse to call their mother. What is the phase of bereavement the patient is experiencing?
    a. Anticipatory grief
    b. Acute distress
    c. Intense grief
    d. Reorganization

Answer 25

ANS: B
The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant’s possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

Question 26

26. During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What should the nurse’s role be?
    a. Take over as much as possible to relieve the pressure.
    b. Encourage grandparents to take over.
    c. Make sure the parents themselves approve the final decisions.
    d. Leave them alone to work things out.

Answer 26

ANS: C
The nurse is always the patient’s advocate. Nurses can offer support and guidance and leave room for the same from grandparents. However, in the end, nurses should strive to let the parents make the final decisions.

Question 27

27. During a follow-up visit, which would the nurse expect not to observe if the parents have progressed to the second stage or phase of grieving?
    a. Guilt, particularly in the mother
    b. Numbness or lack of response
    c. Bitterness or irritability
    d. Fear and anxiety, especially about getting pregnant again

Answer 27

ANS: B
The second phase of grieving, intense grief, encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, as if the parents were still in denial or shock.

Question 28

28. Which would signify that grieving parents had progressed to the reorganization/recovery phase a year after their loss?
    a. The parents say they feel no pain.
    b. The parents are discussing sex and a future pregnancy, even if they have not
    sorted out their feelings yet.
    c. The parents have abandoned those moments of bittersweet grief.
    d. The parents’ questions have progressed from “Why?” to “Why us?”

Answer 28

ANS: B
Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly past the first year, when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, often on anniversary dates. Most couples never abandon it. Recovery is ongoing. Typically a couple’s search for meaning progresses from “Why?” in the acute phase to “Why me?” in the intense phase to “What does this loss mean to my life?” in the reorganizational phase.

Question 29

29. The nurse caring for a family during a loss might notice that survivor guilt sometimes is felt at the death of an infant by which family member?
    a. Siblings
    b. Mother
    c. Father
    d. Grandparents

Answer 29

ANS: D
Survivor guilt sometimes is felt by grandparents, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not.

Question 30

30. When helping the mother, father, and other family members actualize the loss of the infant, what should the nurse do?
    a. Use the words lost or gone rather than dead or died.
    b. Make sure that the family understands that it is important to name the baby.
    c. If the parents choose to visit with the baby, apply powder and lotion to the baby
    and wrap the infant in a pretty blanket.
    d. Set a firm time for ending the visit with the baby so the parents know when to let
    go.

Answer 30

ANS: C
Presenting the baby in a nice way stimulates the parents’ senses and provides pleasant memories of their baby. Nurses must use dead and died to assist the bereaved in accepting reality. Although naming the baby can be helpful, it is important not to create the sense that parents have to name the baby. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different time periods with their baby to say goodbye. Nurses need to be careful not to rush the process.

Question 31

1. Which should the nurse be aware of with regard to helping parents with their decision making about an autopsy?
   a. Autopsies may be important in answering the question “Why?”
   b. Autopsies must be done within a few hours after birth.
   c. The type of autopsy is from head to toe with no possibility of optional types such
   as excluding the head.
   d. The decision for an autopsy needs to be done within 4 hours of birth.

Answer 31

ANS: A
Autopsies may be an important mechanism for answering the question “Why?” if there is a chance the cause of death can be
determined. This information can be helpful in processing grief and perhaps in preventing another loss. There is no rush to perform an autopsy unless evidence of contagious disease or maternal infection is present at the time of death. Options for the type of autopsy, such as excluding the head, should be made available to parents. Parents may need time to make this decision.

Question 34

32. Complicated bereavement
    a. occurs when, in multiple births, one child dies, and the other or others live.
    b. is a state in which the parents are ambivalent, as with an abortion.
    c. is an extremely intense grief reaction that persists for a long time.
    d. is felt by the family of adolescent mothers who lose their babies.

Answer 34

ANS: C
Parents showing signs of complicated grief should be referred for counselling. Multiple births in which not all the babies survive creates a complicated parenting situation, but this is not complicated bereavement. Abortion can generate complicated emotional responses, but they do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but this is not complicated bereavement.

Question 34

33. In helping bereaved parents cope and move on, nurses should keep in mind which of the following?
    a. A perinatal or parental grief support group is more likely to be helpful if the needs
    of the parents are matched with the focus of the group.
    b. When pictures of the infant are taken for keepsakes, no close-ups should be taken
    of any congenital anomalies.
    c. No significant differences exist in grieving individuals from various cultures,
    ethnic groups, and religions.
    d. In emergency situations nurses who are so disposed must resist the temptation to
    baptize the infant in the absence of a priest or minister.

Answer 34

ANS: A
A perinatal or parental grief support group is more likely to be helpful if the needs of the parents are matched with the focus of the group. For example, a religious-based group may not work for nonreligious parents. Close-up pictures of the baby must be taken as the infant was, congenital anomalies and all. Although death and grieving are events shared by all people, mourning rituals, traditions, and taboos vary by culture, ethnicity, and religion. Differences must be respected. Baptism for some religious groups can be performed by a layperson, such as a nurse, in an emergency situation when a priest is not available.

Question 34

34. Which medication can be used to manage postpartum hemorrhage (PPH)?
    a. Coumadin
    b. Methylergonovine
    c. Terbutaline
    d. Magnesium sulphate

Answer 34

ANS: B
Methylergonovine is used to manage PPH. Terbutaline and magnesium sulphate are tocolytics; relaxation of the uterus causes or worsens PPH. Coumadin is an anticoagulant to prevent or treat blood clots.

Question 34

35. Which is a possible alternative or complementary therapy for postpartum depression (PPD) for breastfeeding mothers?
    a. Yoga
    b. Motherwort
    c. St. John’s wort
    d. Wine consumption

Answer 34

ANS: A
Possible alternative or complementary therapies for postpartum depression include acupuncture, acupressure, aromatherapy, therapeutic touch, massage, relaxation techniques, reflexology, and yoga. Motherwort promotes uterine contractions. St. John’s wort has not been proven to be safe for patients who are breastfeeding. Patients who are breastfeeding or have a history of PPD should not consume alcohol.

Question 34

36. Which instruction should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications?
    a. Palpate the fundus daily to ensure that it is soft.
    b. Notify the primary health care provider of any increase in the amount of lochia or
    a return to bright red bleeding.
    c. Report any decrease in the amount of brownish red lochia.
    d. The passage of clots as large as an orange can be expected.

Answer 34

ANS: B
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 over time. Large clots after discharge are a sign of complications and should be reported.

Question 34

39. Anxiety disorders are common mental disorders that affect patients. While providing care to the perinatal patient, a nurse should be aware that one of these disorders is likely to be triggered by the process of labour and birth. This disorder is
    a. phobias.
    b. panic disorder.
    c. posttraumatic stress disorder (PTSD).
    d. obsessive-compulsive disorder (OCD).

Answer 34

ANS: C
In PTSD, patients perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event. Phobias are irrational fears that may lead a person to avoid certain objects, events, or situations. Panic disorders include episodes of intense apprehension, fear, and terror. Symptoms may manifest themselves as palpitations, chest pain, choking, or smothering. OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck their infant once he or she is born, even though they realize that this is irrational.

Question 35

38. Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?
    a. Postpartum depression
    b. Postpartum psychosis
    c. Postpartum bipolar disorder
    d. Postpartum blues

Answer 35

ANS: D
Postpartum or “baby blues” is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported. Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of birth. Hospitalization of the patient is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes.

Question 35

37. If nonsurgical treatment for late postpartum birth hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition?
    a. Hysterectomy
    b. Laparoscopy
    c. Laparotomy d. D&C

Answer 35

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

Question 36

1. Which are risk factors for postpartum hemorrhage (PPH)? (Select all that apply.)
   a. Twin pregnancy
   b. Preterm birth
   c. Magnesium sulphate administration during labour
   d. Mother’s first labour and birth
   e. Forceps-assisted birth
   f. Oxytocin-induced labour

Answer 36

ANS: A, C, E, F
Risk factors for PPH include overdistended uterus (e.g., twin pregnancy), magnesium sulphate administration during labour, forceps-assisted birth, and an oxytocin-induced labour. Preterm birth is not a risk factor. High parity, rather than being a nullipara, is a risk factor.

Question 37

2. Which are considered unusual placental adherences? (Select all that apply.)
   a. Placenta previa
   b. Placenta accrete
   c. Placenta increta
   d. Placenta abruption
   e. Retained placental fragments
   f. Placenta percreta

Answer 37

ANS: B, C, F
Unusual placental adherence can be partial or complete. The following degrees of attachment are recognized: placenta accrete, increta, and percreta. Placenta abruption is not abnormal adherence but rather an abruption from the uterus. Placenta previa is abnormal placement of the placenta rather than abnormal adherence. Retained placental fragments is not considered an unusual adherence.

Question 38

3. Which are adverse effects that the nurse needs to be aware of when caring for a patient with a postpartum hemorrhage (PPH) who is being administrated carboprost tromethamine? (Select all that apply.)
   a. Hypothermia
   b. Bradycardia
   c. Hypotension
   d. Nausea
   e. Diarrhea
   f. Headache

Answer 38

ANS: D, E, F
Possible adverse effects of carboprost tromethamine (Hemabate) are headache, nausea, vomiting, diarrhea, fever, chills, tachycardia, and hypertension.

Question 39

4. Which are administration guidelines for the use of methylergonovine when managing postpartum hemorrhage (PPH)? (Select all that apply.)
   a. Contraindication to its use is pre-eclampsia.
   b. Water intoxication is a common adverse effect.
   c. Withhold drug if maternal BP is >130/85.
   d. Nausea and vomiting are adverse effects.
   e. It is not to be administered to patients with asthma.

Answer 39

NS: A, D
When administering methylergonovine, it is important for the nurse to know that a contraindication to its use is pre-eclampsia and cardiac disease. Adverse effects include nausea and vomiting. The drug should be withheld if the maternal BP is >140/90. There is no contraindication to its use in patients with asthma, as that applies to the administration of tranexamic acid. Water intoxication is an adverse effect when the patient with a PPH is being managed with oxytocin, not methylergonovine.

Question 40

PPH may be sudden and result in rapid blood loss. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss. Astute assessment of circulatory status can be done with noninvasive monitoring. Please match the type of noninvasive assessment that the nurse would perform with the appropriate clinical manifestation or body system.
a. Palpation
b. Auscultation c. Inspection
d. Observation e. Measurement
1. Pulse oximetry
2. Heart sounds
3. Arterial pulses
4. Skin colour, temperature, turgor
5. Presence or absence of anxiety

Answer 40

1. ANS: E
2. ANS: B
3. ANS: A
4. ANS: C
5. ANS: D