OB : Ch 12

1. A nursing student is preparing to give a pregnant woman heparin for a deep vein thrombosis

(DVT). The student questions the dose, as it is higher than what the student has given to other

patients. What response by the perinatal nurse is most appropriate?

A. Have the student hold the dose and double-check the order with the provider.

B. Inform the student that physiological changes in pregnancy require higher doses.

C. Remind the student that large doses are needed to dissolve the existing clot.

D. Tells the student to administer the dose and check results of the next laboratory

draw.

B. The pregnant patient has a greater plasma volume and an increased renal clearance

(due to increased blood flow to the kidneys). The combination of normally

occurring heparin-binding proteins along with the breakdown of heparin often

results in the need for higher doses of heparin during pregnancy.

2. A G2 TPAL 2002 patient experienced a precipitous birth 90 minutes ago. Her infant weighed

4,200 g, and a repair of a second-degree laceration was needed following the birth. The nurse

assesses that the patient's uterus is boggy and deviated to the right. The patient's vaginal

bleeding has increased. Which action by the nurse takes priority?

A. Assess the vital signs, including blood pressure and pulse.

B. Call the health-care provider to examine the woman now.

C. Massage the uterine fundus with continual lower-segment support.

D. Measure and document each used perineal pad to assess blood loss.

C. As the primary caregiver, the registered nurse may be the first person to identify

excessive blood loss and to initiate immediate actions. While another member of the

team calls the physician or nurse-midwife, the nurse should first locate the uterine

fundus and initiate fundal massage.

3. A nurse is caring for a patient who has excessive blood loss postdelivery from uterine atony.

The perinatal nurse notifies the health-care provider while another nurse performs uterine

massage. Which medication does the nurse anticipate being given as the priority?

A. Carboprost (Hemabate)

B. Ergonovine (Ergotrate)

C. Methylergonovine (Methergine)

D. Oxytocin (Pitocin)

D. If the cause of the hemorrhage is uterine atony, continual fundal massage with

lower uterine segment support is mandatory. While one member of the team

massages the fundus, another nurse establishes intravenous access with a large-bore

needle and administers oxytocic drugs, starting with oxytocin.

4. A postpartum patient is hemorrhaging despite receiving several medications and fundal

massage. What action by the nurse takes priority?

A. Begin weighing all used perineal pads.

B. Obtain informed consent for surgery.

C. Place the woman on her left side.

D. Switch the IV solution to dextrose.

B. If more conservative methods do not control postpartum hemorrhage, invasive

surgical procedures are indicated. Procedures include the placement of uterine

packing, balloon tamponade, ligation of the uterine arteries, hypogastric artery

ligation, uterine suturing, embolization procedures, and hysterectomy. The nurse

needs to facilitate obtaining informed consent for an emergency invasive procedure.

5. Approximately 8 hours ago, a woman gave birth after 2.5 hours of pushing. She required an

episiotomy and an assisted birth (forceps). The perinatal nurse assesses a slight bulge in the

perineum and the presence of ecchymosis to the right of the episiotomy. The area feels "full"

and is approximately 4 cm in diameter. The patient describes this area as "tender." What

intervention does the nurse anticipate for this situation?

A. Application of ice

B. Exploratory surgery

C. Incision and drainage

D. Sitz bath every 12 hours

A. This patient has a perineal hematoma. If the hematoma is less than 3 to 5 cm in

diameter, the physician usually orders palliative treatments, such as ice to the area

for the first 12 hours along with pain medication.

6. A postpartum woman has a deep vein thrombosis. The patient states, "I feel anxious and have

some pain in my chest." The patient's respiratory rate is 28 breaths per minute. After initiating

a rapid response, which action by the perinatal nurse takes priority?

A. Administer oxygen.

B. Document the findings.

C. Take a full set of vital signs.

D. Prepare to give pain medication.

A. The presence of dyspnea and tachypnea may signal pulmonary embolism, and the

nurse should summon help immediately to deal with this condition. After that,

administer oxygen, raise the head of the bed, assess vital signs, or begin CPR

immediately if needed.

7. A perinatal clinic nurse develops concerns about a postpartum woman and her infant at the

first well-baby checkup. The nurse has assessed several risk factors for depression. Which

action by the nurse is most appropriate?

A. Administer the Edinburgh Postnatal Depression Scale.

B. Contact Children and Family Services or Child Protective Services.

C. Notify the Visiting Nurses Association and request a home visit.

D. Provide information and teaching on the postpartum blues.

A. If the nurse believes that the new mother is demonstrating signs and symptoms of

postpartum depression, the Edinburgh Postnatal Depression Scale is highly

predictive and can be combined with the informal interview during a routine

postbirth checkup.

8. A perinatal nurse receives reports from the nurse aide on four patients who all gave birth

within the last 4 hours. Which patient should the nurse assess first?

A. Blood loss of 850 mL during cesarean birth

B. Exhausted mother wanting only to rest after childbirth

C. Pulse consistently ranges from 82 to 90 beats/minute

D. Systolic blood pressure changes from 132 to 110 mm Hg

D. A drop in blood pressure by 15%, maternal heart rate over 110 beats/minute or an

oxygen saturation less than 95% may indicate a postpartum hemorrhage. The nurse

should assess the woman whose blood pressure has changed more than 15%.

9. A nurse is assessing a woman who had a postpartum hemorrhage treated with fundal massage

and oxytocin (Pitocin). Which assessment finding would require the nurse to intervene

immediately?

A. Mean arterial pressure of 58 mm Hg

B. Pain of 4 on a pain scale of 1 (least amount) to 10 (most amount) 1 hour after the

pain medication was administered

C. Used perineal pad weight of +80 g in 2 hours

D. Urinary bladder nondistended, no urge to void

A. One of the first signs of hypovolemic shock is a decrease in mean arterial pressure

(MAP). MAP should be at least 60 mm Hg. To determine MAP, add the systolic

pressure to the doubled diastolic pressure, and divide that sum by 3.

10. A woman had a cesarean birth after a prolonged trial of labor. When assessing the patient, the

nurse notes the patient is lethargic, has a pulse of 130 beats/minute, and states, "I'm glad I

have so little lochia; I'm too tired to change my pad." What action by the nurse is most

appropriate?

A. Assess the amount of lochia on the peripad.

B. Cluster the nursing care given to allow uninterrupted sleep.

C. Have the woman get up and attempt to void.

D. Take a full set of vital signs and call the provider.

D. Signs of puerperal infection include tachycardia, malaise, uterine tenderness, and

subinvolution. Lochia can be heavy and foul-smelling or scant and odorless,

depending on the offending organism. The nurse should take a full set of vital signs,

perform a complete assessment, and notify the health-care provider.

11. A postpartum woman presents to the perinatal clinic complaining of extreme breast tenderness

and an inability to express milk on the left side when breastfeeding. What

nonpharmacological comfort measure does the nurse teach this patient?

A. Application of either warm or cold packs

B. Expression of milk every 1-2 hours

C. Ice and elevation of the breast when sitting

D. Menthol-based lotion to draw the heat out

A. This woman has the manifestations of mastitis and will be treated with antibiotics

and analgesics. Comfort measures include applying either warm or cold packs to the

breasts.

12. A nurse is taking care of a pregnant patient diagnosed with idiopathic thrombocytopenia

purpura (IPP) who has just had a vaginal delivery. Which priority action should the nurse

anticipate?

A. Obtain vital signs, check uterine fundus and lochia area q 15 minutes in the first

hour

B. Maintain intravenous access

C. Obtain platelet count, and CBC with differential

D. Obtain informed consent for potential D&C

C. Women who have IPP and just delivered should be closely monitored for potential

decreases on their platelet count. The priority would be to obtain baseline labs,

platelet count, and CBC with differential to assess the patient's hematological status

following delivery.

13. A postpartum woman who had a cesarean birth complains of warmth and pain in one of her

calves. Which assessment should the nurse perform as the priority?

A. Bilateral calf circumference

B. Homans' sign on both legs

C. Lung sounds and oxygen saturation

D. Pedal and popliteal pulses

A. Several clinical manifestations exist for DVT, including pain, calf tenderness, and

leg swelling. The nurse can also assess warmth, redness, and possibly a palpable

cord. The most accurate assessment is to measure and compare calf circumference;

a 2-cm or greater increase on the painful side is an objective finding for DVT.

14. A nurse is assessing a patient who is receiving heparin therapy for a DVT post-partum. Which

finding warrants immediate action?

A. INR results 3.0

B. PRN order for protamine sulfate based on aPPT parameters

C. aPPT results 30 seconds

D. Orders for aPPT, and PTT per protocol

C. Monitoring of therapeutic range for heparin administration for a DVT would indi-

cate that the aPPT should be 1.5 to 2.5 times the control. An aPPT result of 30 sec-

onds would indicate that the medication has not achieved a therapeutic level and per

protocol a bolus dose with increase in titrated amount be initiated.

15. A patient was discharged from the hospital on warfarin sodium (Coumadin) and is now in the

perinatal clinic for follow-up. Which of the following would best indicate to the nurse that

goals for discharge teaching have been met?

A. Chooses aspirin for pain relief

B. Eats large salads three times a week

C. Patient INR of 2.5

D. Patient aPTT of 2 times normal

C. Warfarin therapy is monitored with the PT and INR, and in many places, the INR

has replaced the PT. A therapeutic INR is 2-3.5. This patient's INR is therapeutic.

16. A woman with postpartum depression is being treated with a selective serotonin

reuptake inhibitor (SSRI). What statement by the patient requires further action by the nurse?

A. "Adding St. John's wort has really helped my depression."

B. "I have started using aromatherapy and it helps a little."

C. "Increasing my calcium intake seems to have a positive effect."

D. "My baby seemed sleepier, so I stopped breastfeeding him."

A. St. John's wort has been used to treat depression but cannot be taken with SSRIs

because of the possibility of the patient developing a serious condition known as

serotonin syndrome. This herb can also increase the side effects associated with

SSRIs.

17. A patient has just had a spontaneous vaginal delivery and is experiencing excessive blood

loss. Vital signs are BP 130/98, pulse 92, and respirations 22. What orders should the nurse

anticipate that the physician will order? Select all that apply.

A "Type and cross for 2 units PRBCs."

B "Administer Pitocin 10 units into 1,000 mL Ringer's lactate solution after the placenta has

been delivered."

C. "Administer Methergine 0.2 mg IV prior to the expulsion of the placenta."

D "Decrease rate of intravenous fluids."

E "Maintain pad count."

A. This is correct. With excessive blood loss, the physician may order blood replace-

ment therapy.

B. This is correct. Following expulsion of the placenta, Pitocin is typically adminis-

tered. If the bleeding is excessive, then a Pitocin infusion would be indicated.

E. This is correct. A pad count would be indicated for a patient who has excessive

bleeding in the postpartum period. This would help to alert the nurse to potential

problems and/or clinical response to treatment.

18. A woman is hospitalized after an incision and drainage of a large breast abscess that cultured

methicillin-resistant Staphylococcus aureus. What dietary choices indicate that she has

understood teaching regarding nutrition and wound healing? Select all that apply.

A "Chicken breast."

B "Hard-boiled egg."

C "Orange slices."

D "Spinach."

E "Whole wheat bread."

A. This is correct. Wound healing and recovery from illness require high protein and

vitamin C. Foods high in protein include animal products such as chicken.

B. This is correct. Wound healing and recovery from illness require high protein and

vitamin C. Foods high in protein include animal products such as eggs, cheese, and

milk.

C. This is correct. Wound healing and recovery from illness require high protein and

vitamin C. Foods high in vitamin C include many fruits, such as cantaloupe, kiwi,

oranges, and papaya.

D. This is correct. Wound healing and recovery from illness require high protein and

vitamin C. Foods high in vitamin C include many vegetables, such as spinach,

Brussels sprouts, and all colors of bell peppers.

19. A nurse is triaging a new mother in the exam room whose has a 6-month-old infant with a

chief complaint of anxiety and "just doesn't feel like herself". Which observations would alert

the nurse to the possibility of a postpartum psychosis? Select all that apply.

A "Patient reports that she is sleeping more and is always tired."

B "Patient feels overwhelmed with taking care of the baby."

C "Patient is unaware of what day or time it is when questioned."

D "Patient avoids eye contact and is rocking back and forth in the chair."

E "Patient asks if you will also repeat the questions as her mom is having trouble hearing

them."

C. This is correct. The patient is exhibiting signs of disorientation, which is

significant and can be seen in postpartum psychosis.

D. This is correct. The patient is exhibiting signs of agitation and avoiding eye

contact, which are significant findings and be seen in postpartum psychosis.

E. This is correct. There is no evidence to suggest that there is another person in the

triage room, therefore the patient may be having a hallucination, which is a signif-

icant finding and can be seen in postpartum psychosis.

20. Which nursing actions would be best suited to prevent infections in the puerperium period?

Select all that apply.

A "Change peripad every 6 hours."

B "Use hydrogen peroxide to cleanse perineum."

C "Cleanse perineal area from back to front and pat dry."

D "Apply warm water via a squeeze bottle to clean the perineal area."

E! "Increase fluid intake."

D. This is correct. This is a factual statement and will help to decrease the risk of

infection.

E. This is correct. An increased fluid intake is recommended at this time to help in-

crease urine production, decrease urinary stasis, and prevent urinary tract infec-

tions.