Question 1

To evaluate the desired response of methylergonovine (Methergine), the nurse would assess the patient's

Accepted Answer

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.

Question 2

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?

Accepted Answer

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.

Question 3

To prevent infection of the reproductive tract, the nurse should instruct the patient to

Accepted Answer

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.

Question 4

If the nurse suspects a pulmonary embolism in the patient who suddenly complains of chest pain, she or he should immediately

Accepted Answer

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.

Question 5

If a DVT (deep vein thrombosis) is suspected, the nurse should

Accepted Answer

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.

Question 6

If a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred

Accepted Answer

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.

Question 7

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.)

Accepted Answer

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.

Question 8

As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration?

Accepted Answer

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.

Question 9

The nurse observes the patient as she ambulates to the bathroom. Which clinical finding might indicate development of a DVT (deep vein thrombosis)?

Accepted Answer

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.

Question 10

Before administering methylergonovine (Methergine), the nurse checks the

Accepted Answer

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.

Question 11

Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.)

Accepted Answer

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.

Question 12

Which patient data received during report should the nurse recognize as being at risk for postpartum complications?

Accepted Answer

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.

Question 13

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?

Accepted Answer

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.

Question 14

If the nurse suspects a complication of a low forceps birth labor, she should immediately

Accepted Answer

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.

Question 15

Prior to ambulating the patient whose admission hemoglobin level was 10.2 g/dL to the bathroom, the nurse should

Accepted Answer

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.

Question 16

To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should frequently assess

Accepted Answer

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.

Quiz 18: Postpartum Maternal Complications

To evaluate the desired response of methylergonovine (Methergine) , the nurse would assess the patient's