Nokea
Choose the signs and symptoms that suggest postpartum hemorrhage causing a hematoma.
- A. Rectal pain accompanied by a rising pulse
- B. Cramping accompanied by a steady trickle of blood
- C. Soft uterine fundus and falling blood pressure
- D. Heavy lochia accompanied by tachypnea and dyspnea
Correct Answer: A
Rationale: Hematomas may cause pain and lead to hemodynamic changes such as a rising pulse. Rectal pain is a common sign of a perineal hematoma.
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The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Start an IV bolus. In postpartum hemorrhage (PPH), the priority is to restore circulating volume quickly to prevent shock. Starting an IV bolus with fluids or blood products helps improve perfusion and oxygenation. Choice A is incorrect as warming the person does not address the underlying issue of hypovolemia. Choice B is incorrect as monitoring oxygen saturation is not the immediate priority. Choice C is incorrect as sitting the person up could potentially worsen their condition by reducing venous return.
What would a steady trickle of bright red blood from the vagina in the presence of a firm fundus suggest to the nurse?
- A. Uterine atony
- B. Lacerations of the genital tract
- C. Perineal hematoma
- D. Infection of the uterus
Correct Answer: A
Rationale: The steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests uterine atony. Uterine atony is a condition where the uterus fails to contract effectively after childbirth, resulting in postpartum hemorrhage. The firm fundus indicates that the uterus is not properly contracting to control bleeding, leading to the continuous flow of blood from the vagina. Prompt intervention is crucial to manage uterine atony and prevent further complications such as excessive blood loss.
A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time?
- A. Pulse.
- B. Fundus.
- C. Bladder.
- D. Breast.
Correct Answer: B
Rationale: After delivery, the most critical assessment is to evaluate the fundus to ensure uterine contraction and prevent hemorrhage.
The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
- A. Apply an ice pack to the perineum.
- B. Advise the woman to use a sitz bath after every voiding.
- C. Advise the woman to sit on a pillow.
- D. Teach the woman to insert nothing into her rectum.
Correct Answer: A
Rationale: Applying an ice pack to the perineum helps reduce swelling and provides pain relief after a perineal laceration.
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see?
- A. Diaphoresis.
- B. Lochia alba.
- C. Cracked nipples.
- D. Hypertension.
Correct Answer: B
Rationale: By the second week postpartum, lochia typically transitions to alba (white or yellowish discharge).