CARE STUDY: AN ADOLESCENT WITH A POSTPARTAL COMPLICATION

Pamela Barth is a 17-year-old, GI PO woman transferred to the postpartal service following the birth of a 9-pound 4-
ounce infant boy

CHIEF CONCERN:
“Should I be bleeding this much?”

HISTORY OF PRESENT CONCERN:

Client gave birth to a 9-pound 4-ounce boy under epidural anesthesia at 7:25 a.m. following a 14-hour labor.
Membranes had been ruptured for 26 hours. Modified Crede's maneuver used to deliver placenta. Fifteen U pitocin in
500 mL of lactated Ringer’s administered intravenously following birth. Blood loss from birth estimated at 750 mL. At
present, client reports vaginal bleeding is so heavy she is saturating a perineal pad every 20 minutes.

FAMILY PROFILE:
Lives with mother, two older sisters, five nieces and nephews in a three-bedroom house on a dairy farm. Has
“borrowed” supplies for baby from sisters. Father of child is said to be supportive but did not come to be with her in
labor.

HISTORY OF PAST ILLNESS:

Chickenpox at 5 years: facial acne since she was 12. No major illnesses; no hospitalizations.

GYNECOLOGIC HISTORY:
Menarche at 10 years; cycle duration: 29 days; menstrual flow duration: 5 days. No STIs. Not using a contraceptive
before present pregnancy.

OBSTETRICAL HISTORY:
No previous pregnancies. This pregnancy was not planned but not unwelcome. No complications during pregnancy
except for minimal edema formation; proteinuria of 2+ and blood pressure increase to 140/98 for last 2 weeks.

REVIEW OF SYSTEMS:
Neurologic: Treated for 5 years when younger for “small seizures”. No longer takes medication for this.
Mouth: Severe malocclusion treated with oral braces since age 14.
Breasts: Mild breast engorgement; pleased to be breastfeeding.

PHYSICAL EXAMINATION
General appearance: apprehensive-appearing, slender black woman. T: 98.6°F, BP: 100/60.
HEENT: Integument: approximately five black comedones present on forehead. Mouth: Full upper and lower metal
braces present. No ulcerations or abrasions on gumlines.
Chest: Heart rate: 100 beats per minute. No murmurs present. Lungs: rhonchi present in upper lobes. Respiratory
rate: 22 breaths per minute
Abdomen; Soft. Fundus palpated at 2F above umbilicus and boggy. Massaged and large firm clot 5 cm in diameter
was expelled vaginally. Fundus somewhat firmer following massage but height did not change.
Perineum: Midline episiotomy line intact; no hemorrhoids. Lochia: continuous bright red vaginal flow present; no clots.

LABORATORY RESULTS
 Hemoglobin: 8.9 g/dl.
 WBC: 25,000

DIRECTION: Answer the following items and provide rationalization of your answers. (2 points each item)

Questions 1-14 refer to the case

1. Which factor in Pamela’s health history makes her high risk for hemorrhage during the post partal period?
A. Her placenta was implanted on the posterior uterus.
B. Her baby weighed more than 9 pounds.
C. Her family earns their living caring for dairy cows.
D. Pamela was in labor longer than 12 hours.

RATIONALE:
A. Incorrect, it leads to still birth because of posterior placenta. Also, placenta previa is the one that causes the
mother to bleed that may lead to hemorrhage.
 B. Correct, there may be a uterine atony if the uterus is stretch and enlarged since she is delivering a 9
pounds baby.
C. Incorrect, because dairy milks are good source of calcium.
D. Incorrect, prolonged labor can be dangerous to the baby. It may cause low oxygen levels for the baby and
abnormal heart rhythm in the baby.

2. To estimate blood loss postpartally, you assess Pamela’s perineal pads. A saturated perineal pad contains
approximately how much blood?
A. 10 to 20 mL
B. 25 to 50 mL
C. 100 Ml
D. 250 Ml

RATIONALE:
A. Incorrect, a 10 to 20 mL saturated perineal pad indicates a light hemorrhage
B. Correct, a normal saturated perineal pad is at approximately 25-50ml
C. Incorrect, 100 mL indicates a heavy blood loss
D. Incorrect, 250 mL of blood may lead to hemorrhage

3. A common drug used to cause a uterus to contract postpartally to prevent or control bleeding is
A. Levodopa.
B. Prilosec.
C. Oxytocin
D. Meperidine

RATIONALE:
A. Incorrect, levodopa is used to manage Parkinson's symptoms such as tremors, stiffness, and slowness of
movement.
B. Incorrect, Prilosec is used to treat symptoms of gastroesophageal reflux disease
C. Correct, Oxytocin is used to improve contractions during labor. It also used to reduce bleeding after
childbirth.
D. Incorrect, Meperidine is used to help relieve moderate to severe pain

4. Massaging a uterus is a measure to control postpartal bleeding. To do this, you would

A. use a light rapid effleurage technique for this.
B. place one hand in the vagina to steady the cervix.
C. always massage from side to side to decrease pain.
D. place one hand at the base of the uterus to anchor it.

RATIONALE:
A. Incorrect, effleurage technique is used to increase the blood circulation
B. Incorrect, one hand should be placed at the vaginal canal and the other hand should be against the other
uterus body
C. Incorrect, massaging from side to side doesn’t control bleeding, in fact it only reduces the pain
D. Correct, to avoid hemorrhage, place one hand at the base of the uterus to anchor it. Massaging the
uterus, on the other hand, is used to manage postpartum bleeding.

5.Which factor in Pamela’s history puts her at high risk for postpartal infection of the uterus?
A. Birth from a lithotomy position
B. Rupture of membranes over 24 hours
C. Birth of a 9-pound male infant
D. Breastfeeding her infant on demand

RATIONALE:
A. Incorrect, lithotomy position can’t develop an infection of the uterus
B. Correct, rupture of membranes over 24 hours may increase the risk of infection such as
chorioamnionitis, this happens more often when the bag of waters is broken for a long time before
birth and this let bacteria in the vagina move up into the uterus.
C. Incorrect, giving birth to a large baby doesn’t cause to infection
D. Incorrect, breastfeeding provides a nutrient for the baby, not infection.

6. Postpartal infection of the uterus is termed

 A. vaginitis.
B. cystitis.
C. Endometritis
D. Cervicitis

RATIONALE:
A. Incorrect, is an inflammation of the vagina that is typically caused by a fungal or bacterial infection
B. Incorrect, cystitis is basically an infection of the bladder
C. Correct, is an infection of the uterus lining or upper genital tract that some women develop following
childbirth.
D. Incorrect, cervicitis is basically an inflammation or infection of the cervix

7. Pamela has a perineal hematoma. A common cause of this is

A. a clotting defect from the interaction of epidural anesthesia.
B. bruising of the perineum from a vertex presentation.
C. bleeding from the placing of perineal episiotomy sutures.
D. urine seeping into the perineum from the anterior bladder

RATIONALE:
A. Incorrect, clotting is an effect of using epidural anesthesia, and epidural anesthesia is used during surgery
and childbirth.
B. Incorrect, bruising of the perineum may cause infection
C. Correct, hematomas are commonly caused by bleeding during the placement of perineal episiotomy
sutures. This is due to the marks and lacerations that the operation left behind.
D. Incorrect, urine seeping commonly result from trauma and can be a complication such abscess formation
and electrolyte imbalances

8. Pamela has a WBC of 25,000 mm3. For a postpartal woman, you would assess this as
A. below average.
B. a normal count.
C. an elevated count.
D. normal if it consists of only lymphocytes.

RATIONALE:
A. Incorrect, a low WBC may cause viral infections that temporarily disrupt the work of bone marrow
B. Correct, a normal postpartal WBC count is 25,000 mm3.
C. Incorrect, an elevated account of WBC can indicate an underlying problem, such as infection, stress,
inflammation, trauma, allergy, or certain diseases
D. Incorrect, test result of lymphocytes differs from WBC

9. Which temperature best signals postpartal infection?

A. 101°F at 8 hours postpartum
B. 102°F immediately after birth
C. 99°F at 2 weeks postpartum
D. 101.2°F on the third postpartal day

RATIONALE:
A. Incorrect, postpartum fever is defined as a temperature of 101.6 degrees F or greater for the first 24 hours
B. Incorrect, having a temperature of 102 F after birth is normal
C. Incorrect, 99 degrees F does not indicate that there is an infection
D. Correct, a temperature of <100 degrees fahrenheit on the third day signals that there is an
occurrence of infection that needs to be monitored.

10. All women in the postpartum period are at high risk for thrombophlebitis. This is because
A. placental toxins may lead to anticoagulation.
B. vaginal tears can lead to minimal infections.
C. fetal blood mixes with maternal blood at birth.
D. stasis of lower extremity vessels due to dilation.

RATIONALE:
A. Incorrect, this is not a cause of thrombophlebitis
B. Incorrect, vaginal tears can lead to infection if untreated
 C. Incorrect, mixed fetal blood and maternal blood at birth does not linked to thrombophlebitis
D. Correct, Thrombophlebitis is a common complication of endometrium infection caused by dilation of
the lower extremity veins.

11. If a woman develops a deep vein thrombus in the femoral vein, a common intervention would be to
A. keep her legs in a dependent position.
B. apply alcohol soaks to the site.
C. apply moist heat over the site.
D. use a sterile needle to aspirate the clot.

RATIONALE:
A. Incorrect, it should be elevated her legs and avoid massaging the area.
B. Incorrect, there is no evidence to relieve pain by soaking alcohol to the site of DVT
C. Correct, use warm compress can reduced the inflammation in the site of DVT.
D. Incorrect, it is not recommended to do and it is not the procedure of intervention for deep vein thrombus.

12. Warfarin (Coumadin) is a common drug prescribed for deep vein thrombus. Which factor in Pamela’s history
would make you question an order for this drug postpartally?
A. She is breastfeeding her newborn.
B. She is less than 25 years of age.
C. She has no history of a previous blood clot.
D. She has been exposed to dairy cows.

RATIONALE:
A. Correct, Anticoagulants like warfarin are passed by breast milk and too low to affect baby’s
blood clotting.
B. Incorrect, people under the age of 25 is possibly have a deep vein thrombus
C. Incorrect, there is no prior history of a blood clot.
D. Incorrect, no evidence to prove that exposing to dairy cows will prescribed warfarin drugs.

13. The antidote for Warfarin (Coumadin) is

A. acetylsalicylic acid.
B. vitamin K.
C. Heparin.
D. serotonin

RATIONALE:
A. Incorrect, it is risk for increase bleeding
B. Correct, if overdose occurs or anticoagulation needs to be immediately reversed, the antidote
is vitamin K.
C. Incorrect, Heparin prevents prothrombin from converting to thrombin.
D. Incorrect, Serotonin is a hormone-stabilizing drug.

14. Which of the following denotes the correct technique for fundal massage for a postpartum client exhibiting a large
amount of blood on the perineal pad?
A. Compressing the fundus on one side while supporting the other side of the uterus
B. Massaging above the symphysis pubis while one hand supports the uterine fundus
C. Pressing deeply into the abdomen while compressing the fundus with both hands
D. Supporting the fundus while massaging the uterus just above the symphysis pubis
RATIONALE:
A. Incorrect, it is not appropriate to do. when performing a fundal massage, one hand is placed just above
the symphysis pubis to support the lower uterine segment while the fundus is gently but firmly
massaged in a circular motion.
B. Incorrect, there will be no effective uterine contractions
C. Incorrect, it is not the fundal massage technique
D. Correct, it is the appropriate techniques of fundal massage and effectively stimulating uterine
contraction.

15. When teaching a childbirth education class on infection prevention after delivery, the nurse would instruct the
woman to perform perineal care how often?
 A. After each voiding or defecation
B. Every 8 hours
C. Once each day
D. When she has perineal pain

RATIONALE:
A. Correct, to decrease the accumulation of microorganism in the perineal area
B. Incorrect, it takes long to clean the perineal, it should be washed at least 1 to 2 hours
C. Incorrect, the accumulation of the microorganism is already spread in the perineal area
D. Incorrect, since there is no pain, it should be frequently do the perineal care for postpartum mother

16. A client who is 24 hours postpartum has the following morning vital signs: Temperature 100° F; BP 124/78; P58;
R16. The nurse should do which of the following?
A. Assess the vital signs hourly instead of every 4 hours.
B. Report the changes in vital signs to the physician.
C. Retake the pulse rate after the client ambulates.
D. Recognize the client’s vital signs are normal

RATIONALE:
A. Incorrect, the frequent vital signs to assess should be every hour.
B. Incorrect, Stable vital signs are not recommended to report to the physician
C. Incorrect, ambulate can affect the pulse rate
D. Correct, documented normal vital signs of the client that indicate no complications.

17. A client begins preterm labor and the physician orders terbutaline sulfate (Brethine). After its administration, the
nurse assesses the client for the therapeutic effect of

a. Reduction of pain in the perineal area

b. Decrease in blood pressure from 120/80 to 90/60
c. Decrease in frequency and duration of contractions
d. Dilation of the cervix from 1 to 1.5 cm for every hour of labor.

RATIONALE:
A. Incorrect, anti-inflammatory medications is for reduction of pain and not recommended during preterm
labor.
B. Incorrect, a tocolytic drug side effect including terbutaline sulfate (breathine) which one of the nursing
considerations to do.
C. Correct, Terbutaline sulfate indication is to prevent premature labor which way of action to relax
the muscle of the uterus to unable to deliver the fetus.
D. Incorrect, there some medication to dilate cervix and inducing delivery of the baby.

18. The postpartum client is bleeding heavily 2 hours after delivery. The fundus of the uterus is firm; uterus at the
center of the abdomen. Which of the following actions should the nurse do next?

A. change perineal pads

B. notify the physician
C. massage the uterus
D. check perineum

RATIONALE:
A. Incorrect, to prevent infection
B. Incorrect, notify the physician for further complication.
C. Incorrect, to reduce bleeding and cramping of uterus
 D. Correct, look for vaginal tearing or laceration that causes excessive bleeding in the perineum.

19. Which of the following techniques during labor and delivery can lead to uterine inversion?
A. Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head
B. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation
C. Massaging the fundus to encourage the uterus to contract
D. Applying light traction when delivering the placenta that has already detached from the uterine wall

RATIONALE:
A. Incorrect, a pushing technique that helps to aid mother giving birth
B. Correct, if the placenta is not already detached to the uterine wall and uterus is relaxed, at the
same time tugging on the cord that leads uterus to invert.
C. Incorrect, to stimulate uterine contraction
D. Incorrect, Counter pressure was used to regulated cord traction and it helps to remove placenta.

20. Lochia normally disappears after how many days postpartum?

A. 5 days
B. 7-10 days
C. 18-21 days
D. 28-30 days

RATIONALE:
A. Incorrect, it will last in 5 days after birth
B. Correct, lochia normally disappears after 10 days. The color gets lighter from reddish to whitish
and scantier.
C. Incorrect
D. Incorrect

21. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is:
A. Encourage the mother to ambulate to relieve It is not appropriate to push deeply into the abdomen,
and only one should be done. The hand that will be used to rub the fundus.the pain in the leg
B. Instruct the mother to apply elastic bondage from the foot going towards the knee to improve
venous return flow
C. Apply warm compress on the affected leg to relieve the pain
D. Elevate the affected leg and keep the patient on bedrest

RATIONALE:
A. Incorrect, Mothers are encouraged to walk to avoid unnecessary blood loss
B. Incorrect, Elastic stockings help to increase circulation and avoid venous stasis.
C. Incorrect, warn compress in the infected area can be block the blood flow
D. Correct, Bed rest prevent the possible dislodging of the thrombus and keeping the affected leg
elevated to help reduce the inflammation

22. Which of the following denotes the correct technique for fundal massage for a postpartum client exhibiting a large
amount of blood on the perineal pad?
A. Compressing the fundus on one side while supporting the other side of the uterus
B. Massaging above the symphysis pubis while one hand supports the uterine fundus
C. Pressing deeply into the abdomen while compressing the fundus with both hands
D. Supporting the fundus while massaging the uterus just above the symphysis pubis

RATIONALE:
E. Incorrect, it is not appropriate to do. when performing a fundal massage, one hand is placed just above
the symphysis pubis to support the lower uterine segment while the fundus is gently but firmly
massaged in a circular motion.
F. Incorrect, there will be no effective uterine contractions
G. Incorrect, it is not the fundal massage technique
H. Correct, it is the appropriate techniques of fundal massage and effectively stimulating uterine
contraction.
23. Cefelita, 38 years old multipara is admitted with a tentative diagnosis of femoral thrombophlebitis. The nurse
assesses the patient with
A. burning sensation
B. leg pain
C. abdominal pain
D. increased lochial flow
. RATIONALE:
A. Incorrect, puerperal infection can possible cause burning sensation during urination
B. Correct, leg pain is commonly associated with femoral thrombophlebitis during pregnancy.
C. Incorrect, abdominal pain can be caused Constipation, bloating or development of gas in the stomach
which is nothing to do with femoral thrombophlebitis.
D. Incorrect, increased lochial flow can be associated with uterine atony

24. In the immediate postpartum period the action of methylergonovine is to

A. cause sustained uterine contractions.
B. cause intermittent contractions.
C. relax the uterus.
D. induce sleep so the mother can rest after an exhausting labor.
RATIONALE:
A. Correct, methylergonovine use to improve muscle tone, strength and timing of uterine
contraction in order to help deliver the placenta and help to control bleeding
B. Incorrect, Terbutaline sulfate, a tocolytic medication that cause intermittent contractions
C. Incorrect, Uterotonic drug use to relax the uterus
D. Incorrect, Analgesic drug use to induce sleep so the mother can rest after an exhausting labor.

25. Management of thrombosis and thrombophlebitis includes

A. Checking the homan’s sign
B. Monitoring signs of inflammation in the lower extremities.
C. Starting on anticoagulant therapy
D. A and B
E. All of the above

RATIONALE:
A. Correct
B. Correct
C. Correct
D. Correct, all the choices are correct. Checking the homan’s signs can assess thrombosis and
thrombophlebitis, monitoring signs of inflammation in the lower extremities can be associated
with thrombophlebitis and thrombosis, giving anticoagulant therapy/medication helps to reduce
pain, prevent blood clothing and dissolve blood clots.

“To accomplish great things

We must not only act but also dream
Not only plan, but also believe”
Prepared by:
Araceli Flores Surat< MAN