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What is a risk factor for uterine atony?
- A. small for gestational age
- B. primipara
- C. multiple gestation
- D. intrauterine growth restriction
Correct Answer: C
Rationale: Multiple gestation increases the risk of uterine atony due to over-distention of the uterus.
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The nurse is performing an assessment of the uterus 30 minutes after a normal delivery and finds the fundus to be soft and boggy. IV Pitocin is infusing at 150 mL/hr. What is the priority nursing intervention?
- A. Increase the Pitocin, assess the fundus in 15 minutes, and update the licensed provider.
- B. Perform external massage of the uterus until it is firm, assess for additional bleeding on the pad, and update the licensed provider.
- C. Notify the provider of the increase in blood loss.
- D. Assist the patient to the bathroom and reassess the fundus after the patient voids.
Correct Answer: B
Rationale: The correct answer is B because a soft and boggy fundus after delivery indicates uterine atony, which can lead to postpartum hemorrhage. Performing external massage of the uterus will help stimulate contractions and firm up the fundus. Assessing for additional bleeding is crucial to monitor for hemorrhage. Updating the licensed provider is important for further management.
Choice A is incorrect because simply increasing Pitocin without addressing the uterine atony may not resolve the issue. Choice C is incorrect as notifying the provider of increased blood loss is not the immediate priority; addressing the uterine atony is. Choice D is incorrect as assisting the patient to the bathroom does not address the soft and boggy fundus issue.
The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation?
- A. Blood pressure may be elevated from prenatal conditions.
- B. Respirations are increased due to activity of labor.
- C. Changes in blood pressure may not be an immediate sign.
- D. Heart rate may increase with intensity of labor.
Correct Answer: C
Rationale: The correct answer is C because changes in blood pressure may not be an immediate sign of hemorrhage. Hemorrhage can occur rapidly and cause a drop in blood pressure, but it may not be the first sign observed. Vital signs such as blood pressure can fluctuate for various reasons, making it challenging to solely rely on them to identify hemorrhage risk. Elevated blood pressure from prenatal conditions (A) and increased respirations due to labor activity (B) are more likely to be expected and can be explained by those specific factors. Heart rate increasing with the intensity of labor (D) is a common physiological response and may not necessarily indicate hemorrhage.
A woman is receiving patient-controlled analgesia (PCA) post -cesarean section. Which of the following must be included in the patient teaching?
- A. The client should monitor how often she presses the button.
- B. The client should report any feelings of nausea or itching to the nurse.
- C. The family should press the button whenever they feel the woman is in pain.
- D. The family should inform the nurse if the client becomes sleepy.
Correct Answer: B
Rationale: It is important for the client to report any adverse effects, such as nausea or itching, to the nurse while using PCA.
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.
What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2–3 hours
- C. pulse 72
- D. WBCs 10,000
Correct Answer: D
Rationale: Painful fundal massage can indicate a potential infection.