Question 1 of 9
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On assessment, the postpartum nurse notes a firm fundus, bright red blood oozing from the vagina, and a saturated perineal pad. What diagnosis would the nurse expect based on these assessment findings?
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- Vaginal hematomaA vaginal hematoma is not visible without a speculum, and women often complain of pressure and pain inside the vagina (a feeling of “fullness”). A vaginal hematoma may occur due to an operative vaginal delivery (forceps or vacuum extraction), an episiotomy, or a primiparous birth. A vaginal hematoma is trapped blood, and therefore no bleeding will be present.
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- Placenta accretaA placenta accreta is diagnosed when the placenta invades the myometrium of the uterus. With a placenta accreta, the fundus would not be firm; however, there would be bleeding.
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- Vaginal lacerationA vaginal laceration that was not discovered or repaired after a vaginal delivery would create an oozing of blood that is typically bright red (frank) in color.
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- Uterine inversionA uterine inversion is diagnosed when the uterus turns inside out followed by a large amount of bleeding. The fundus would not be firm. A uterine inversion is a medical emergency.
Question 2 of 9
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The nurse understands that which conditions are risks for a uterine inversion?
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- Precipitous deliveryA precipitous delivery is not a risk factor for uterine inversion but is a risk factor for a laceration.
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- Short umbilical cordA short umbilical cord is a risk factor for a uterine inversion because it places extra traction on the cord during delivery, which could pull the placenta and invert the uterus.
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- PolyhydramniosPolyhydramnios is not a risk factor for uterine inversion but is a risk factor for uterine atony.
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- Fundal implantation of the placentaFundal implantation of the placenta is a risk factor for a uterine inversion; as traction is placed on the umbilical cord during delivery, there is a higher risk to invert the uterus.
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- Prolonged laborA prolonged labor is a risk factor for uterine inversion because a prolonged labor creates an overworked and “tired” uterus, which makes it vulnerable to inversion after delivery.
Question 3 of 9
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Which risk factor places a woman at risk for subinvolution of the uterus?
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- ChorioamnionitisSubinvolution of the uterus is the delayed return (longer than 24 hours) of the uterus to normal size after delivery. Pelvic infections, including chorioamnionitis, place a woman at risk for subinvolution.
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- Forceful traction of the umbilical cordForceful traction of the umbilical cord is not a risk factor for subinvolution but is a risk factor for uterine inversion.
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- Vacuum extractionA vacuum extraction is not a risk factor for subinvolution but is a risk factor for a vaginal laceration or vaginal hematoma.
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- Precipitous deliveryA precipitous delivery is not a risk factor for subinvolution but is a risk factor for a laceration.
Question 4 of 9
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A nurse is caring for the following labor patients. Which patients would the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)?
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- G1 P0000, delivered a 29-week fetal demise vaginally after 8 hours in laborA fetal demise does not increase the risk for a woman to have a PPH after delivery.
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- G2 P1001, delivered a 4200-g neonate vaginally after 4 hours of laborFetal macrosomia (birth weight >4000 g) places a woman at higher risk for PPH after delivery due to an overstretched uterus.
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- G2 P0010, delivered a 3750-g neonate by cesarean section for breech presentationAn infant at normal weight delivered by cesarean section for breech presentation does not increase the risk for a woman to have a PPH after delivery.
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- G4 P3003, delivered a 3500-g neonate by cesarean section with a placenta accretaA placenta accreta increases the risk for a woman to have a PPH due to the risk for retained placenta, which can lead to uterine atony.
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- G3 P0200, delivered a 3900-g neonate vaginally after 36 hours in laborA prolonged labor, in this case 36 hours, increases a woman’s risk for a PPH due to an overworked and “tired” uterus.
Question 5 of 9
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A woman, 1 day postpartum, is being carefully monitored after a significant postpartum hemorrhage (PPH). Which finding would the nurse report to the health care provider?
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- Urine output of 160 mL for the past 8 hoursOliguria (urine output <30 mL/h) should be reported, as this is a late sign of hypovolemic shock.
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- Weight loss of 2 lb since deliveryWeight loss after a childbirth is an expected finding and does not need to be reported to the health care provider.
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- Pulse rate of 68 beats/minA pulse rate of 68 beats/min is within normal limits. Any pulse rate that is bradycardic (<60 beats/min) or tachycardic (>100 beats/min) should be reported to the health care provider.
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- Fundus firm at the umbilicusA firm fundus at the level of the umbilicus is a reassuring sign that the uterus in contracting and returning to normal size and location. If the fundus was boggy or rising above the umbilicus, the nurse would report that finding to the health care provider.
Question 6 of 9
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A woman delivered a 9-lb, 10-oz baby 1 hour ago. When the nurse arrives to perform the 15-minute assessment, the patient says that she “feels all wet underneath.” The nurse discovers that both perineal pads are completely saturated and that the patient is lying in a 6-inch-diameter puddle of blood. After calling for help, which action would the nurse take next?
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- Assess the fundus for firmness.Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first attempt to firm the fundus through firm, but not vigorous, massage.
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- Estimate the blood loss by weighing the perineal pads.Estimating the blood loss is important; however, the nurse should prioritize stopping the active bleeding before estimating blood loss.
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- Check the perineum for lacerations.Checking the perineum for lacerations is important, but the nurse should first determine whether uterine atony is the cause for the bleeding before examining the perineum.
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- Manually remove any contents in the uterus.A retained placenta can cause a postpartum hemorrhage; however, the health care provider, not the nurse, is responsible for manually removing any contents from the uterus. The nurse should first massage the fundus to determine if there is uterine atony.
Question 7 of 9
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A multiparous woman 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 woman void and massages her fundus, but the patient’s fundus remains difficult to find and the lochia remains bright red and heavy. Which action would the nurse take next?
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- Vigorously massage the fundusThe nurse should continue to massage the fundus; however, the fundus should never be vigorously massaged because of the risk for uterine inversion. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider.
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- Notify the health care providerTreatment of a postpartum hemorrhage requires the collaboration of the nurse and the health care provider. The nurse should remain with the patient and call the health care provider.
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- Recheck the vital signsThe nurse has already taken vital signs, and they remain unchanged. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider.
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- Insert an indwelling catheterThe nurse has already had the patient void to empty her bladder. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider.
Question 8 of 9
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The nurse understands that an early postpartum hemorrhage is defined as an estimated blood loss greater than __ mL in the first 24 hours after a vaginal delivery.
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- Your answer: 500Correct answer: 500A postpartum hemorrhage is defined as an estimated blood loss of greater than 500 mL after a vaginal delivery. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider if the blood loss is greater than 500 mL.
Question 9 of 9
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The nurse recognizes that a steady trickle of bright red blood from the vagina in the presence of a firm fundus may indicate which condition?
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- Uterine atonyUterine atony results in a boggy uterus and dark red lochia with or without the presence of clots.
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- Retained placentaRetained placental fragments result in a boggy uterus that is above the umbilicus. Bleeding typically is dark red lochia with large amounts of clots.
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- Infection of the uterusAn infection of the uterus results in a boggy uterus due to the inability of the uterus to contract because of the infection. Lochia may be normal, or it may have a foul smell in the presence of pus.
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- A laceration within the genital tractUndetected lacerations bleed slowly and continuously until repaired with sutures. Bleeding from lacerations is uncontrolled by uterine contractions, and it is typically bright red.