1. A perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause for this bleeding? a. Uterine atony b. Uterine inversion c. Vaginal hematoma d. Vaginal laceration - ANS: A Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage; however, it is not the most likely source of this client's bleeding. Further, 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 for vaginal hematoma is pain, not the presence of profuse bleeding. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus. 2. What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony? a. Establishing venous access b. Performing fundal massage c. Preparing the woman for surgical intervention d. Catheterizing the bladder - ANS: B The initial management of excessive postpartum bleeding is a firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, fundal massage is the initial intervention. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention is to assess the uterus. After uterine massage, the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from properly contracting. 3. What is the most common reason for late postpartum hemorrhage (PPH)? 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, cervical lacerations, and coagulation disorders of the decidua may also cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments. 4. Which client is at greatest risk for early postpartum hemorrhage (PPH)? a. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress b. Woman with severe preeclampsia on magnesium sulfate whose labor is being induced c. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor d. 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, a multiparous woman with an 8-hour labor, and a primigravida in spontaneous labor with preterm twins do not indicate risk factors or causes of early PPH. 5. The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis? a. Absence of cyanosis in the buccal mucosa b. Cool, dry skin c. Calm mental status d. Urinary output of at least 30 ml/hr - ANS: D Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation during 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. 6. The most effective and least expensive treatment of puerperal infection is prevention. What is the most important strategy for the nurse to adopt? a. Large doses of vitamin C during pregnancy b. Prophylactic antibiotics c. Strict aseptic technique 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 extremely 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 administered to manage infections; they are not a cost-effective measure to prevent postpartum infection. Limiting protein and fat intake does not help prevent anemia or prevent infection. 7. What is one of the initial signs and symptoms of puerperal infection in the postpartum client? a. Fatigue continuing for longer than 1 week b. Pain with voiding c. Profuse vaginal lochia with ambulation d. Temperature of 38° C (100.4° F) or higher on 2 successive days - 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