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Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Lowdermilk: Maternity & Women's Health Care, 10th Edition



Chapter 34: Postpartum Complications

Test Bank

MULTIPLE CHOICE

1. A perinatal nurse is caring for a woman in the immediate postbirth period. Assessment
reveals that the woman is experiencing profuse bleeding. The most likely etiology for
the bleeding is:
a. Uterine atony
b. Uterine inversion
c. Vaginal hematoma
d. Vaginal laceration

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
clients bleeding. Furthermore, if the woman 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 is pain, not the presence of profuse bleeding.
A vaginal laceration may cause hemorrhage; however, it is more likely that profuse
bleeding will result from uterine atony. A vaginal laceration should be suspected if vaginal
bleeding continues in the presence of a firm, contracted uterine fundus.

DIF: Cognitive Level: Comprehension REF: 825
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Diagnosis

2. A primary nursing responsibility when caring for a woman experiencing an obstetric
hemorrhage associated with uterine atony is to:
a. Establish venous access
b. Perform fundal massage
c. Prepare the woman for surgical intervention
d. Catheterize the bladder

ANS: B
The initial management of excessive postpartum bleeding is firm massage of the uterine
fundus.
Although this may be a necessary intervention, the initial intervention is fundal massage.
The woman may need surgical intervention to treat her postpartum hemorrhage, but the
initial nursing intervention is to assess the uterus.
Test Bank
Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
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After uterine massage the nurse may want to catheterize the client to eliminate any bladder
distention that may be preventing the uterus from contracting properly.

DIF: Cognitive Level: Application REF: 826
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Implementation

3. A perinatal nurse caring for a postpartum woman understands that late postpartum
hemorrhage (PPH) is most likely caused by:
a. Subinvolution of the uterus
b. Defective vascularity of the decidua
c. Cervical lacerations
d. Coagulation disorders

ANS: A
Late PPH may be the result of subinvolution of the uterus. Recognized causes of
subinvolution include retained placental fragments and pelvic infection.
Although defective vascularity of the decidua may cause PPH, late PPH typically results
from subinvolution of the uterus, pelvic infection, or retained placental fragments.
Although cervical lacerations may cause PPH, late PPH typically results from
subinvolution of the uterus, pelvic infection, or retained placental fragments.
Although coagulation disorders may cause PPH, late PPH typically results from
subinvolution of the uterus, pelvic infection, or retained placental fragments.

DIF: Cognitive Level: Comprehension REF: 826
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Planning

4. Which client is at greatest risk for early postpartum hemorrhage (PPH)?
a. A primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean
birth for fetal distress
b. A woman with severe preeclampsia on magnesium sulfate whose labor is being
induced
c. A multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
d. A primigravida in spontaneous labor with preterm twins

ANS: B
Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a
smooth muscle relaxant, thereby contributing to uterine relaxation and atony.
A primiparous woman being prepared for an emergency cesarean birth for fetal distress
does not indicate risk factors or causes of early PPH.
A multiparous woman with an 8-hour labor does not indicate risk factors or causes of early
PPH.
A primigravida in spontaneous labor with preterm twins does not indicate risk factors or
causes of early PPH.

Test Bank
Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
34-3
DIF: Cognitive Level: Analysis REF: 825
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Planning

5. When caring for a postpartum woman experiencing hemorrhagic shock, the nurse
recognizes that the most objective and least invasive assessment of adequate organ
perfusion and oxygenation is:
a. Absence of cyanosis in the buccal mucosa
b. Cool, dry skin
c. Diminished restlessness
d. Urinary output of at least 30 ml/hr

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.
The presence of cool, pale, clammy skin is associated with hemorrhagic shock.
Hemorrhagic shock is associated with lethargy, not restlessness.

DIF: Cognitive Level: Analysis REF: 831
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Assessment

6. The most effective and least expensive treatment of puerperal infection is prevention.
What is the most important strategy?
a. Large doses of vitamin C during pregnancy
b. Prophylactic antibiotics
c. Strict aseptic technique, including handwashing, by all health care personnel
d. Limited protein and fat intake

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

DIF: Cognitive Level: Application REF: 835
OBJ: Client Needs: Safe and Effective Care Environment
TOP: Nursing Process: Planning

Test Bank
Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
34-4
7. One of the first symptoms of puerperal infection to assess for in the postpartum woman
is:
a. Fatigue continuing for longer than 1 week
b. Pain with voiding
c. Profuse vaginal bleeding with ambulation
d. Temperature of 38 C (100.4 F) or higher on 2 successive days starting 24 hours
after birth

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. The definition used in the
United States continues to be the presence of a fever of 38 C (100.4 F) or higher on 2
successive days of the first 10 postpartum days, starting 24 hours after birth.
Fatigue is a late finding associated with infection.
Pain with voiding may indicate a urinary tract infection (UTI), 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.

DIF: Cognitive Level: Comprehension REF: 833
OBJ: Client Needs: Health Promotion and Maintenance
TOP: Nursing Process: Assessment

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

ANS: B
Almost all instances of acute mastitis can be avoided by 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.

DIF: Cognitive Level: Comprehension REF: 835
OBJ: Client Needs: Health Promotion and Maintenance
TOP: Nursing Process: Planning



Test Bank
Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
34-5

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 woman is bleeding
b. Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml
after cesarean birth to define the condition as PPH
c. If anything, nurses and doctors tend to overestimate the amount of blood loss
d. Traditionally, PPH has been classified as early or late with respect to birth

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
cesarean birth constitute PPH.
Medical personnel tend to underestimate blood loss by as much as 50% in their subjective
observations.

DIF: Cognitive Level: Knowledge REF: 824
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Diagnosis

10. Lacerations of the cervix, vagina, or perineum are also causes of PPH. Factors that
influence the causes and incidence of obstetric lacerations of the lower genital tract
include all except:
a. Operative or precipitate birth
b. Adherent retained placenta
c. Abnormal presentation of the fetus
d. Congenital abnormalities of the maternal soft parts

ANS: B
Abnormal adherence of the placenta occurs for reasons unknown. Attempts to remove the
placenta in the usual manner are unsuccessful and laceration or perforation of the uterine
wall may result. This disorder does not influence lower genital tract lacerations.
Lacerations of the perineum are the most common of all lower genital tract injuries and
often occur with both precipitate and operative births. These are classified as first, second,
third, and fourth degree.
Abnormal presentation, position of the fetus, and relative size of the presenting part and the
birth canal may contribute to lacerations of the lower genital tract.
Congenital abnormalities, previous scarring from infection or injury, and a contracted
pelvis may influence injury to the lower genital tract followed by hemorrhage.

DIF: Cognitive Level: Analysis REF: 825
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Assessment

Test Bank
Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
34-6
11. A woman who has recently given birth complains of pain and tenderness in her leg. On
physical examination, the nurse notices warmth and redness over an enlarged,
hardened area. The nurse should suspect ______ and should confirm the diagnosis by
________.
a. Disseminated intravascular coagulation (DIC); asking for laboratory tests
b. von Willebrand disease (vWD); noting whether bleeding times have been extended
c. Thrombophlebitis; using real-time and color Doppler ultrasound
d. Thrombocytopenic purpura; drawing blood for laboratory analysis

ANS: C
Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely
thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm
diagnosis.
The diagnosis of DIC is made according to clinical findings and laboratory markers.
Physical examination reveals unusual bleeding. Petechiae may appear around a blood
pressure cuff on the womans arm. Excessive bleeding may occur from the site of a slight
trauma such as a venipuncture site.
Symptoms of vWD, a type of hemophilia, include recurrent bleeding episodes, prolonged
bleeding time, and Factor VIII deficiency. A risk for postpartum hemorrhage (PPH) exists
and does not present as a warm or reddened area in an extremity.
Idiopathic or immune thrombocytopenic purpura (ITP) is an autoimmune disorder in which
the life span of antiplatelet antibodies is decreased. Increased bleeding time is a diagnostic
finding and the risk of postpartum uterine bleeding is increased.

DIF: Cognitive Level: Analysis REF: 833
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Assessment

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

ANS: D
Placenta abruptio is premature separation of the placenta as opposed to partial or complete
adherence. This occurs between the twentieth week of gestation and delivery in the area of
the decidua basalis. Symptoms include localized pain and bleeding.
Placenta accreta is a recognized degree of attachment. With placenta accreta there is slight
penetration of the trophoblast into the myometrium.
Placenta increta is a recognized degree of attachment that results in deep penetration of the
myometrium.
Test Bank
Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
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Placenta percreta is the most severe degree of placental penetration that results in deep
penetration of the myometrium. Bleeding with complete placental attachment occurs only
when separation of the placenta is attempted after delivery. Treatment includes blood
component therapy and in extreme cases, hysterectomy may be necessary.

DIF: Cognitive Level: Comprehension REF: 826
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Planning

MULTIPLE RESPONSE

1. Medications used to manage postpartum hemorrhage (PPH) include (choose all that
apply):
a. Oxytocin
b. Methergine
c. Terbutaline
d. Hemabate
e. Magnesium sulfate

ANS: A, B, D
Oxytocin, methergine, and hemabate are medications used to manage PPH.
Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or
worsens PPH.

DIF: Cognitive Level: Comprehension REF: 827
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Implementation

COMPLETION

1. ____________________ is the most common postpartum infection.

ANS:
Endometritis
Endometritis usually begins as a localized infection at the placental site; however, it can
spread to involve the entire endometrium. Assessment for signs of endometritis may reveal
a fever, elevated pulse, chills, anorexia, fatigue, pelvic pain, uterine tenderness, or
foul-smelling profuse lochia.

DIF: Cognitive Level: Comprehension REF: 834
OBJ: Client Needs: Health Promotion and Maintenance
TOP: Nursing Process: Diagnosis