Care analysis for pamela PDF

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CARE STUDY: AN ADOLESCENT WITH A POSTPARTAL COMPLICATIONPamela Barth is a 17-year-old, GI PO woman transferred to the postpartal service following the birth of a9-pound 4-ounce infant boyCHIEF CONCERN:“Should I be bleeding this much?”HISTORY OF PRESENT CONCERN :Client gave birth to a 9-pound 4-ounce...

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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

Questions 1-14 refer to the case 1. Which factor in Pamela’s health history makes her high risk for hemorrhage during the postpartal 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: If the baby is large then there is a possibility that the uterus will be overdistended and it will have a hard time to contract after delivery which risks the mother for hemorrhage. Posterior placenta is normal. Financial stability is unrelated to the subject. The client is primipara so a labor longer than 12 hours is normal as long as it does not go beyond 20 hours.

2. To estimate blood loss postpartally, you assess Pamela’s perineal pads. A saturated perineal pad contains approximately how much blood? A. B. C. D.

10 to 20 mL 25 to 50 mL 100 Ml 250 Ml

Rationale: Weighing a pad is an effective way to determine the amount of blood in pad. 1 gram is equal to 1 ml and a saturated pad normally weighs 25 to 50 grams; approximately 25 to 50 ml of blood. 10 to 20 ml blood is scant. 100 ml to 250 ml indicates is a lot and indicates 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: Oxytocin (Pitocin) is the most common drug used for the uterus to contract. If the uterus successfully contracts then it can put pressure on the placenta site and prevent bleeding. Levodopa is indicated to control muscle movement. Prilosec is a drug for heartburn. Meperidine is indicated for pain or inflammation.

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: In doing uterine massage, the other hand is at the base of the uterus for support and to prevent uterine inversion. Effleurage increase blood circulation and is not necessary, the other hand is not place in the vagina but at the base of the uterus to prevent uterine inversion. Massaging is not side to side but it is on top of the uterus.

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: In normal cases, when the membranes are ruptured the baby should follow but if it is not the case then this puts the mother at risk for infection because the longer membranes are ruptured before delivery, the longer time the microorganisms can invade and infect the uterus. Femoral thrombophlebitis can occur from lithotomy position. Birth of 9-pound male infant which is large can over distend the uterus which can cause postpartum hemorrhage. If there is problem with breastfeeding then it possibly can lead to mastitis.

6. Postpartal infection of the uterus is termed A. vaginitis. B. cystitis. C. Endometritis D. Cervicitis Rationale: Endometritis is an infection of the lining of the uterus on the postpartum period. Vaginitis is inflammation of the vagina. Cystitis is inflammation of the bladder. Cervicitis is inflammation 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 blade. Rationale: Having an episiotomy causes perineal hematoma because episiotomy stiches can result to oozing of blood that can collect in the tissues surrounding the anus. Perineal hematoma occurs at the site of episiotomy or laceration repair if a vein was punctured during suturing. The other choices do not cause or are not common cause of the complication. 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: WBC count during postpartum period is increased to 20, 000 mm3 to 30, 000 mm3 due to the stress of labor. It is not below or elevated count and it is not consisting only of lymphocytes.

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: Temperature is usually elevated on the first 24 hours after labor especially if the woman is not drinking enough fluid. Temperature of 99°F is normal. If a woman’s temperature is 101.2°F on the third postpartal day, she can be suspected to have endometritis because fever of endometritis manifests itself on the third or fourth postpartal day but it should be confirmed or checked thoroughly because on the third or fourth day of postpartum period, breast filling occurs and it also causes elevation of temperature.

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: Dilation of lower extremity veins is still present in the postpartum period as a result of pressure of the fetal head during pregnancy and birth so blood circulation is sluggish which can lead to “inflammation with the formation of blood clots” (thrombophlebitis). The other choices do not put the patient at risk for thrombophlebitis.

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: Moist heat decreases inflammation or pain and it can interfere with blood clotting which can promote good circulation. Ambulation should be done too for good circulation. Applying alcohol is not necessary and aspiration of clot is not a common intervention.

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: Coumadin is passed in breastmilk and since it is anticoagulant it can cause bleeding. The other choices do not need to be questioned for the order of the drug.

13. The antidote for Warfarin (Coumadin) is A. acetylsalicylic acid. B. vitamin K. C. Heparin. D. Serotonin Rationale: Vitamin K is administered to prevent bleeding and it is the antidote for Coumadin. Heparin is another anticoagulant. ASA or Aspirin is a blood thinner. Serotonin deplete platelets that are necessary for blood clotting, thus, it prevents blood coagulation and increase risk of bleeding.

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: Supporting the fundus while massaging the uterus just above the symphysis pubis provides support to the lower uterine segment while stimulating contraction of the fundus; it prevents inversion of uterus. If the fundus is not supported while massaging the uterus then it can lead to inversion of the uterus. Also, one should not massage above the symphysis pubis because it would not provide effective uterine contractions. One hand is used to massage the uterus and it is not necessary to press deep into the abdomen.

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: Frequent perineal care can prevent invasion of microorganisms or reduces the number of microorganisms present. Every 8 hours is not frequent enough. Once daily will not be effective to prevent growth of microorganisms. Perineal care when she has perineal pain does not relieve pain and this may also be a sign of infection.

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. B.

Assess the vital signs hourly instead of every 4 hours. 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: Elevation of temperature on the first 24 hours postpartum is normal because of slight dehydration during labor. The vital signs are within normal limits so there is no need to alert the physician. The pulse rate is round 50 to 90 bpm on the 1st to 2nd day postpartum so counting pulse rate after client ambulates is not necessary.

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. b. c. d.

Reduction of pain in the perineal area Decrease in blood pressure from 120/80 to 90/60 Decrease in frequency and duration of contractions Dilation of the cervix from 1 to 1.5 cm for every hour of labor.

Rationale: Terbutaline sulfate (Brethine) is a tocolytic drug that is indicated for reducing or suppressing contractility of the uterus. It does not reduce pain or inflammation. Generally, tocolytic drugs are contraindicated to patients with preeclampsia as they can increase blood pressure so terbutaline does not decrease blood pressure. Since the drug is used to stop or decrease uterine contraction, it cannot hasten cervix dilatation because cervical dilatation occurs during uterine contractions.

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: Check the perineum because there may be perineal lacerations that’s why there is heavy bleeding then afterwards, notify the physician. There is a heavy bleeding and changing perineal pads will not help to stop it. The uterus is already firm which means that it is contracting so no need to massage it.

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: Strongly tugging the umbilical cord to deliver the placenta especially if it is relaxed can cause uterine inversion. Placental separation should not be hastened and one should not pull when the uterus is not contracting. Fundal pressure and massaging uterus if done properly cannot lead to uterine inversion. Light traction is applied when delivering the 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: Normally, lochia disappears after 10 days postpartum. Lochia rubra (red) is at 1-3 days postpartum period. Lochia serosa (pink/brown) is at 3-10 days postpartum period. Lochia alba (white) is at 10-14 days postpartum period. It is not less than 7 days and does not usually go beyond 14 days.

21. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is: A. Encourage the mother to ambulate to relieve 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: It is the appropriate intervention among the choices because if a woman already has thrombophlebitis, then bed rest prevents the possible dislodging of the thrombus and keeping the affected leg elevated helps reduce the inflammation and promotes venous return. 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: Supporting the fundus while massaging the uterus just above the symphysis pubis provides support to the lower uterine segment while stimulating contraction of the fundus; it prevents inversion of uterus. If the fundus is not supported while massaging the uterus then it can lead to inversion of the uterus. Also, one should not massage above the symphysis pubis because it would not provide effective uterine contractions. One hand is used to massage the uterus and it is not necessary to press deep into the abdomen. 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: From the term of the complication itself, the site is at the femur. The femoral, saphenous or popliteal veins are affected which are located on the leg. There is inflammation when thrombophlebitis occurs so there is definitely pain and since we are talking about femoral thrombophlebitis then there is “leg pain”. Burning sensation, abdominal pain and increased lochia flow are not signs or symptoms of the complication. . 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: Methylergonovine is an oxytocic agent or drug which means that it helps in uterine contractions. The drug is usually used when there is subinvolution in order to sustain uterine contractions for the uterus to return to its prepregnancy stage. It does not relax the uterus or cause intermittent contractions because it is administered to fix the strength and timing of contractions. It does not induce sleep so the mother can rest.

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: Checking Homan’s sign is necessary because positive Homan’s sign can be seen in patients with Femoral Thrombophlebitis and it is used to detect Deep Vein Thrombosis. Monitoring signs of inflammation in the lower extremities is needed because saphenous vein, which is a vein in the leg is commonly affected in certain types of thrombosis or thrombophlebitis. Since there is blood clotting, anticoagulants or blood thinners are administered. “To accomplish great things We must not only act but also dream Not only plan, but also believe” Prepared by: Araceli Flores Surat< MAN...