Exam (elaborations)
Chapter 22 Nursing Care of the Family During the Postpartum Period
- Course
- Maternal child nursing
- Institution
- Rutgers School Of Nursing
Chapter 22 Nursing Care of the Family During the Postpartum Period
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Chapter 22: Nursing Care of the Family During the Postpartum PeriodMULTIPLE CHOICE
1. What is the most likely cause of postpartum hemorrhage in a 25-year-old multiparous woman
(G3T2P0A0L2) who gave birth 4 hours ago to a 4300 g boy after augmentation of labour with
oxytocin?
a. Retained placental fragments
b. Unrepaired vaginal lacerations
c. Uterine atony
d. Puerperal infection
ANS: C
The most likely cause of postpartum bleeding, combined with these risk factors, is uterine
atony. Although retained placental fragments may cause postpartum hemorrhage, this
typically would be detected in the first hour after delivery of the placenta and is not the most
likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause
bleeding, they typically would occur in the period immediately after birth. Puerperal infection
can cause subinvolution and subsequent bleeding, but it typically would be detected 24 hours
after delivery.
DIF: Cognitive Level: Analysis REF: p. 569
OBJ: Nursing Process: Assessment
2. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has
completely saturated a perineal pad within 15 minutes. What is the nurse’s initial response?
a.
Ringer’s lactate solution. Begin
an intravenous (IV) infusion of
b. Assess the woman’s vital signs.
c. Call the woman’s primary health care
provider.
d. Massage the woman’s fundus.
ANS: D
The nurse should assess the uterus for atony. When the uterus is atonic, the fundus should be
massaged gently and clots expelled. Uterine tone must be established to prevent excessive
, blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would
not be the first action. Blood pressure is not a reliable indicator of impending shock from
impending hemorrhage; assessing vital signs should not be the nurse’s first action. The
physician would be notified after the nurse completes the assessment of the woman.
DIF: Cognitive Level: Application REF: p. 571 | Emergency box OBJ:
Nursing Process: Implementation
3. A woman gave birth vaginally to a 4400 g girl yesterday. Her primary health care provider has
written orders for perineal ice packs, use of a sitz bath TID, and a stool softener. What
information is most closely correlated with these orders?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anaesthesia.
d. The woman has had an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations,
and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-
assisted birth may be used in conjunction with an episiotomy, which would indicate these
interventions. Use of epidural anaesthesia has no correlation with these orders.
DIF: Cognitive Level: Comprehension REF: p. 572 OBJ: Nursing Process: Planning
4. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status,
positive; rubella titre, 1:8 (EIA 0.6); hematocrit, 30%. How would the nurse best interpret these
data?
a.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within
72 hours of birth.
d. A Kleihauer-Betke test should be Rubella
vaccine should be given. performed.
ANS: A
For women who are serologically not immune (titre of 1:8 or enzyme immunoassay level less
than 0.8), a subcutaneous injection of rubella vaccine is recommended in the immediate
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