482 Exam 2 Blueprint Questions and Complete Answers Graded A+.

482 Exam 2 Blueprint Questions and Complete Solutions Graded A+ Male Factor Infertility - Types/causes - Answer: *disruption of testicular or ejaculatory funtion *hormonal disorders *genetic disorders Male Factor Infertility - Disruption of funciton - Answer: *varicoceles - veins in testicles are large and cause them to overheat (heat effects number/shape) *trauma - effects production > lower number *unhealthy habits (smoking, drinking, drugs) *use of certain medications and supplements *cancer treatment - chemo; radiation; therapy *medical conditions - diabetes; cystic fibrosis *autoimmune disorders *infections Male Factor Infertility - Hormonal disorders - Answer: improper function of hypothalamus and/or pituitary gland - both are responsible for release of hormones responsible for normal testicular function (conditions such as a tumor on the pituitary can cause too much prolactin, etc) *congenital or adrenal hyperplasia *exposure to too much estrogen *exposure to too much testosterone *cushing's syndrome *too much glucocorticoids Male Factor Infertility - Genetic disorders - Answer: may cause no or low numbers of sperm to be produced disorders such as: *kleinfelters syndrome *y chromosome microdeletion *myotonic dystrophy Risk factors for male infertility - Answer: age overweight or obese substance use including smoking, excessive alcohol, and marijuana exposure to testosterone exposure to radiation frequent high temp exposure to testes (wheelchair bound; frequent hot tub) certain meds - flutamide; cyproterone; bicalutamide; spironolactone; ketoconazole; cimetidine exposure to environmental toxins like pesticides, led, cadmium, or mercury Female Factor infertility - Types/causes - Answer: *disruption of ovarian function *fallopian tube obstruction *abnormal uterine contour Female Factor infertility - Disruption of ovarian function - Answer: *PCOS (Polycystic Ovarian Syndrome ) - most common cause of female infertility *diminished ovarian reserve *functional hypothalamic amenorrhea *improper function of hypothalamus and pituitary gland *premature ovarian insufficiency *menopause Female Factor infertility - Fallopian tube obstruction - Answer: *pelvic infection *endometriosis *hx of ruptured appendix *hx abdominal surgery Female Factor infertility - Abnormal uterine contour - Answer: fibroids and other anatomical abnormalities How does increase in age decrease a woman's chances of having a baby? - Answer: *she has a smaller number of eggs left *her eggs are not as healthy *she is more likely to have health conditions that cause infertility problems *she is more likely to have a miscarriage perinatal loss - Answer: non-voluntary end of pregnancy from conception, during pregnancy, and up to one year of the newborns life choosing to end a pregnancy due to life limiting or fatal diagnosis is still non-voluntary miscarriage (timeframe) - Answer: <20 weeks stillbirth (timeframe) - Answer: >20 weeks neonatal death (timeframe) - Answer: first 28 days of life infant mortality (timeframe) - Answer: first year of life how can infertility and LGBTQ experiences be considered a reproductive loss? - Answer: psychosocially, the impact of learning one is infertile can be equally as devastating as suffering a loss during pregnancy. the diminished ability or inability to conceive and have offspring can cause an individual to mourn in the same way as someone who has experienced spontaneous abortion the need for medical intervention within the LGBTQ community can be felt as a loss as individuals cope with being unable to reproduce in a "natural" way. therapeutic communication in reproductive loss - THE DO's! - Answer: follow the lead of the family call the baby a baby/by its name repeat asks normalize the experience encourage making memories "this isn't your fault" "i am here to support and guide you" therapeutic communication in reproductive loss - THE DONT's! - Answer: don't call it a fetus "fetal demise" give opinions, share beliefs/faith don't pressure don't offer cliches don't judge don't compare ways nurses can guide parents in making memories with baby after a loss: - Answer: Give the family as much time as they need with their child Discuss photographs Creating memorial items and healing experiences Remember that all trauma is individual and relative This is the ONLY time they will have with their baby, sacred space Don't pressure - but DO repeat asks Be clear about your intention - to support the parents (i.e., dad who is afraid to hold baby - normalize it, ask again) what are two reasons why guiding the family to make memories with a perinatal loss imortant? - Answer: it normalizes the experience it reduces future regrets during labor and delivery of a stillborn fetus, what are some important actions for the nurse to take with the clients and their families - Answer: let the client be in complete control of the process - this is a vulnerable time in which the client feels naturally out of control. letting the client have as much control, and whenever possible, is important. do no rush the labor and delivery unless medically necessary *make sure to encourage the client eats, drinks, and sleep *create as many choices for the client as possible *create a safe and low-stimulus space as much as possible *go slow - be gentle what is potentially the single most important action that a nurse can take in response to somebody experiencing a loss, whether it be a perinatal loss, or a loss felt by infertility or the LGBTQ experience? - Answer: VALIDATE! VALIDATE! VALIDATE! there is no blanket statement for this action. it will vary on a case by case basis. know how to read your client, understand what they are going through, and validate appropriately psychosocial implication of infertility - Answer: *it effects both partners *can cause anxiety and depression *can result in a negative social stigma Infertility has significant negative social impacts on the lives of infertile couples and particularly women, who frequently experience violence, divorce, social stigma, emotional stress, depression, anxiety and low self-esteem. definition of infertility - Answer: the inability of a couple to conceive after 12 months of regular intercourse without use of contraception in women of less that 35 years of age. OR the inability of a couple to conceive after 6 months of regular intercourse without the use of contraception in women of more that 35 years of age key components of taking a sensitive sexual health hx of LGBTQ individuals - Answer: *take it with clothes on *ask if it is ok to discuss and explain *desire, behavior, identity *dont assume anything *"have you had any gender affirming surgery" *ask if they would like a preferred name listed, what is the name i should using for insurance purposes *use inclusive language and preferred pronouns *8 P's what are the 8 P's - Answer: *preferences - "what terms do you use" (for body parts/genitalia) *partners - one or more than one? what is their gender identity? *practices - what kinds of sex? toys/accessories? which body parts? *protection from STI - what barriers are used? any sex acts w/o barriers? PrEP? *past hx of STI - have you had? where? what type *pregnancy - thought about it? contraceptives? preservation? *pleasure - do you get pleasure/enjoy sex? pain/discomfort? *partner abuse - forced sex or violence? do you feel safe? types of interpersonal discrimination in health care for LGBTQ population: - Answer: name-calling harassment verbal abuse physical abuse refusal to provide services types of structural discrimination in health care for LGBTQ populations - Answer: health coverage and insurance legal barriers housing education employment common experiences with health care that LQBTQ people face: - Answer: coverage exclusions postponing needed treatment negative experience and bias having to teach providers use "genitals" instead of - Answer: vulva, vagina, penis, testicles use "external area," "external pelvic area," "outside" instead of - Answer: vulva use "internal organs," "organs you retain" instead of - Answer: uterus, ovaries, cervix use "chest" instead of - Answer: breasts use "bleeding" instead of - Answer: period, menstruation risk factors for postpartum depression - Answer: The most common risk factors identified were: *high life stress *lack of social support *current or past abuse *prenatal depression *marital or partner dissatisfaction. *premenstrual mood disorder *history of depression The 2 strongest risk factors for PPD were prenatal depression and current abuse. symptoms of postpartum depression - Answer: *preoccupation with thoughts of death (in parent or baby) *hyper vigilance *trouble concentrating *crying spells *feeling overwhelmed *other typical depressive symptoms treatment of postpartum depression - Answer: *PPD has a natural course of gradual improvement around 6 months after birth treatments include: *SSRIs - commonly, zoloft or paxil (for at least 6 months) *herbal therapies - st. john's wart (not proven safe for breast feeding) *dietary supplements - omega 3, riboflavin, vitamin b-2 *massage; exercise; aromatherapy; acupuncture *peer support (groups) *relationship counceling screening for postpartum depression - Answer: should happen soon after childbirth. early detection is important. should happen continually after childbirth, including at 2 week follow up appointment, pediatric appointments, phone calls and home visits after discharge. AAP recommends maternal screening at 1, 2, and 4 month infant visits Edinburgh Postnatal Depression Scale - Answer: most used screening tool for PPD. 10 questions asking about feelings within the past week. max score of 30 with score of 12 or more needing further assessment. translated into 58 languages PPD partner symptoms - Answer: in the first year, 4% of fathers will experience depression, although that number could be as high as 50% in actuality fatigue frustration; anger; irritability withdrawal indecisiveness inpatient nursing care and education for PPD - Answer: educate on the early recognition and prevention fo PPD educate the client on when to call the provider nursing care for PPD in the home/community - Answer: *calls and home visits weekly until PP follow up *provide assessment and counseling *community resources include temporary childcare or foster care, meals on wheels, homemaker service, mother's-day-out programs, support groups *encourage partner supports *referral to mental health professionals hormones that facilitate ovulation - follicle stimulating hormone - Answer: produced by pituitary - regulates ovaries and testes stimulates growth of ovarian follicles before release of an egg. also increased estrogen hormones that facilitate ovulation - luteinizing hormone - Answer: stimulates the release of the egg hormones that facilitate ovulation - estrogen - Answer: simulated via FSH and LH causes egg to mature and be released inhibits LH after ovulation hormones that facilitate ovulation - progesterone - Answer: maintains uterine lining inhibits LH after ovulation steps of menstrual cycle/fertilization process - Answer: Pituitary produces FSH and LH —> FSH and LH stimulate egg cells to develop in the follicles of the ovaries —> follicle produces estrogen —> ^estrogen signal pituitary to stop FSH release and ^LH which causes the most mature egg to burst out of the follicle and ovary (ovulation) —> empty follicle releases progesterone which thickens endometrium in preparation for implantation -> if implantation does not occur, estrogen and progesterone levels decrease and a period occurs. ovulation - Answer: the process of releasing a mature ovum into the fallopian tube takes place between the 13-15 day of the 28 day cycle where does firtilization take place - day 0 - Answer: most distal end of fallopian tube fertilization - day 7 - Answer: zygote implants on the wall of the uterus stages of development - fertilized egg - conception to day 14 - Answer: fertilized ovum stages of development - fertilized egg - day 15 to 8 weeks - Answer: embryo most critical time; when organs begin to present stages of development - fertilized egg - 9 weeks to birth - Answer: fetus identical twins - Di/Di - Answer: separate placenta and sac cleavage: days 1-3 low rish identical twins - Mo/Di - Answer: separate sac, same placenta cleavage: days 4-8 moderate risk identical twins - Mo/Mo - Answer: same sac and placenta cleavage: days 8-13 high risk (cord tangling) identical twins - conjoined - Answer: cleavage: days 13-15 how is pregnancy dated? - Answer: from the first day of the LMP (last menstrual period) how is fetal development dated? - Answer: from conception if last expected period was 3 weeks ago, but it didnt happen, and you are pregnant... how pregnant are you? - Answer: 7 weeks pregnant 3 weeks since last expected period + 4 weeks prior to the being the first day of you last menstrual period. very preterm - Answer: less than 32 weeks moderate preterm - Answer: 32-34 weeks late preterm - Answer: 34-36 6/7 weeks early term - Answer: 37-38 6/7 weeks full term - Answer: 39-40 6/7 weeks late term - Answer: 41-41 6/7 weeks labor is usually induced at or around 41 weeks post term - Answer: >42 weeks function of placenta - Answer: Endocrine function - (early function) produces 4 hormones necessary to maintain pregnancy and support embryo/fetus Metabolic function - Protection, Respirations, Excretion, Endocrine, Nutrition, Storage oxygen and CO2 diffuse in and out through placenta development of placenta - Answer: *begins to form at implantation *maternal-placental-embryonic circulation is in place by day 17 when the embryonic heart starts beating *forms from trophoblasts of the chorionic villi *placenta is complete at 12 weeks and continues to grow until the 28th week chorionic villi - Answer: These are finger like projections that form the fetal portion of the placenta. By the 8th week, chorionic villi sampling is possible. presumptive signs of pregnancy - Answer: amenorrhea, nausea, breast tenderness, deepening pigmentation, urinary frequency, quickening (first movements of fetus - around 16 weeks) probable signs of pregnancy - Answer: (examiners objective findings) *Positive pregnancy test (endocrine/at home tests) *enlarge abdomen uterus, *Gooddells signs - significant softening of the cervix *Chadwick sign - blood flow increase to cervix and vagina around 4 weeks, causing them to turn purplish-red *hegars signs - softening in consistency of the uterus *ballottement - feeling baby's head "bobble" with digital vagina examination *basal body temp increase positive signs of pregnancy - Answer: audible fetal heartbeat fetal movement felt by examiner ultrasound or x-ray visualization of fetus 1st trimester - Answer: weeks 1-13 2nd trimester - Answer: 14-26 weeks 3rd trimester - Answer: 27-40 weeks When is the first prenatal visit? - Answer: within the first trimester (12 weeks) how often are prenatal visits between weeks 16-28 - Answer: monthly how often are prenatal visits between weeks 29-36 - Answer: bi-weekly (every two weeks) how often are prenatal visits between weeks 36-40/41 - Answer: weekly group prenatal care - Answer: education and peer support done in a group setting with outcomes of decreased preterm birth, decrease in inadequate care for the community, increase in breastfeeding initiation, and better psychological outcomes members still receive one-on-one care with a provider (group prenatal care is typically geared toward the minority and socioeconomically disadvantaged, expectant mother population) labs including in initial prenatal visit - Answer: HGB/HCT blood type and Rh rubella and varicella tigers urine dipstick STI pap hep B HIV urine pregnancy tests - considerations - Answer: home tests are the same as clinical tests they are very sensitive false-negative can result if taken too early: wait at least a week from the time of the expected date of your last period before taking the test. education to be provided during the first prenatal visit - Answer: expectations nutrition and vitamins alcohol and substance use exercise safety teratogens danger signs common discomforts fetal development how do you determine the estimated due date (EDD) - Answer: from the Last Menstrual Period 40 weeks ~9 calendar months 10 lunar months (28 days) nutrition in pregnancy - key points - Answer: *calcium/calcium rich foods are important *fats (including saturated) are no longer considered bad - fetal neuro development *vegan diets may need supplement (b vitamins, iron, protein vit D, calcium, omega3) *iron deficiency anemia is common exercise in pregnancy - key points - Answer: continue to exercise, it is good for you! however, avoid activities like: contact sports skydiving hot yoga scuba mountain climbing 3rd trimester calls for adjustments to level of activity safety education during pregnancy - key points - Answer: *you center of gravity is changing! this could potentially put you at risk for falls when performing certain activities. watch out for you posture (lordosis development); lift anything; bending over, etc. *seat belt use lordosis - Answer: abnormal anterior curvature of the lumbar spine (sway-back condition) teratogens/toxins education - key points - Answer: in everyday environment (watch out for): toxoplasmosis (don't scoop cat litter box) lead asbestos avoid seafood, for risk of high levels of mercury; and avoid raw or undercooked meats, hot dogs, and lunch meats for risk of listeria) 1st trimester - common discomforts - Answer: nausea and vomiting (morning sickness) breast tenderness constipation vaginal discharge fatigue food cravings/aversions frequent urination heartburn mood swings 1st trimester - danger signs - Answer: severe abdominal pain significant vaginal bleeding severe dizziness rapid weight gain severe nausea & vomiting fever physical exam in first trimester - Answer: think head-to-toe assessment: *height/weight/BMI (pre-pregnancy weight) *BP/pulse/RR *auscultate heart and lungs *thyroid *breast exam *inspect skin - color, vario sixties *abdomen: palpate fundus, liver, FHT *pelvic: speculum/cervical changes *pelvic: bimanual exam - uterine size and softening cervical changes - Goodell's sign - Answer: softening of cervical tip cervical changes - Chadwick's sign - Answer: Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion. cervical changes - Hegar's sign - Answer: softening of the lower uterine segment: anteflexion; pressure on bladder cervical changes - operculum - Answer: mucus plug vaginal changes - leukorrhea - Answer: white or gray discharge from the vagina other vaginal changes in the first trimester include - Answer: chadwick's sign - bluish-purple discoloration lower pH: protection against infection increased glycogen: more prone to yeast infection darkening of perineum vulvar varicosities abdominal assessment - key points - Answer: Leopold's Maneuver - done during the 3rd trimester to reposition the baby if necessary fundal height - measure from symphysis pubis to top of fundus FHT - in the quadrant with the clearest sound common indication for ultrasound during pregnancy - Answer: to confirm pregnancy to confirm viability to determine gestational age to rule out ectopic pregnancy to detect multiple gestation to determine causes of vag bleeding use for visualization during chorionic villi sampling - done thre the vag with a speculum. taking a little bit of the a CV (diagnostic) detect maternal abnormalities (bicornuate uterus, ovarian cysts, fibroids) benefits of vaginal ultrasound versus abdominal ultrasound - Answer: it is more accurate however, it is also more invasive what are the most commonly used substances during pregnancy - Answer: alcohol, tobacco, marijuana (most commonly used illicit drug abrupt discontinuation of opioids in a dependent pregnant person can cause ... - Answer: preterm labor, fetal distress, and stillbirth untreated addiction during pregnancy can lead to ... - Answer: abruption, IUGR, stillbirth, preterm labor, and fetal distress medication assisted therapy - Answer: methadone or buprenorphine used to prevent erratic opioid levels and reduce likelihood of complications fetal and newborn effects of tobacco use - Answer: thromboembolic disease respiratory complications spontaneous abortion (SAB), preterm birth, IUGR, placenta previa, placental abruption, low birth weight, PPROM fetal and newborn effects of alcohol use - Answer: *increased risk of SAB, stillbirth, and preterm birth *fetal alcohol spectrum disorder (FASD) *fetal alcohol syndrome (FAS) is the most severe >dysmorphic facial features, growth deficiency, and CNS abnormalities exposure to alcohol is the most common preventable cause of cognitive impairment no amount is considered safe Neonatal Abstinence Syndrome (NAS) - Answer: a condition in which a child, at birth, goes through withdrawal as a consequence of maternal drug use characteristics of neonatal abstinence syndrome - Answer: *neurologic excitability: hyperactivity, irritability, sleep disturbances *GI dysfunction: uncoordinated suckling, swallowing, vomiting *autonomic signs: fever, sweating, nasal stuffiness Eat, Sleep, Console Model - Answer: used to reduce need for medication in babies with NAS *keep infant with birth parent *encourage breastfeeding *promote skin to skin *supplement feed for weight gain what to monitor for in a birthing individual with a substance use disorder - Answer: mood disorders relapse risk what is the most common endocrine disorder associated with pregnancy? - Answer: diabetes when does the diagnosis for gestational diabetes typically occur? - Answer: during the second half of pregnancy what is the cause of gestational diabetes? - Answer: The placenta! Placental hormone production can cause a decrease in insulin production and temporary insulin resistance the pancreas, stressed by the adaptation of pregnancy, falls behind on insulin production an increase in prevalence of gestational diabetes is due to what? - Answer: mean maternal age and weight ^age = higher risk how does the need for insulin change during pregnancy? - Answer: insulin need drops during the first trimester, then it rises beginning week 14-16 Intrauterine growth restriction (IUGR) - Answer: Growth rate does not meet expected norms macrosomia - Answer: large-bodied baby commonly seen in diabetic pregnancies what complications can pregestational diabetes cause - Answer: intrauterine growth restriction (IUGR) macrosomia how is pregestational diabetes controlled in pregancy - Answer: it needs to be controlled very tightly and IV insulin used during labor When is gestational diabetes screened for in pregnancy? - Answer: 24-28 weeks what is a common birth complication of gestational diabetes - Answer: macrosomia what are some risk factors for gestational diabetes - Answer: Age > 25 yr. Obesity Family history of type II diabetes Polycystic Ovarian Syndrome (PCOS) pregnancy history components that are a significant risk for gestational diabetes - Answer: Macrosomia>4500g Polyhydramnios - amniotic fluid increases in this case due to fetal polyuria Unexplained stillbirth Miscarriage Infant with congenital anomalies maternal risk from having gestational diabetes - Answer: Operative birth Increased risk of future Type 2 DM Increased risk of future cardiovascular problems Increased risk of PPD fetal risks from gestational diabetes - Answer: Macrosomia Birth trauma - shoulder dystocia Hypoglycemia - neonatal, leads to hypothermia and jaundice oral glucose tolerance test - Answer: performed to confirm a diagnosis of diabetes mellitus and to aid in diagnosing hypoglycemia steps of oral glucose tolerance test - Answer: draw fasting BG give 50g sugar test BG after 1hr > 130mg/dl = positive (1 hr) if positive: 2nd test/different day fasting = >95 1hr = >180 2hr = >155 3hr = >130 gestational diabetes management - Answer: check blood glucose every hour BG monitoring, urinate testing diet and exercise Fetal surveillance possible pharm therapy (PO glyburide, metformin) (25% will need insulin) patient education for diabetes during pregnancy - Answer: diet and nutrition/exercise education medication education postpartum risks (developing T2DM if GDM is left untreated) S/Sx of hypoglycemia S/Sx of hyperglycemia signs and symptoms of hypoglycemia - Answer: nervousness weakness irritable headache hunger blurry vision tingling extremities signs and symptoms of hyperglycemia - Answer: polydipsia polyuria polyphagia abdominal pain fruity breath nausea flushed/dry skin what does the term "centering" refer too? - Answer: group prenatal care what are the common DANGER SIGNS in all three trimesters of pregnancy - Answer: severe abdominal pain and cramping vagina bleeding severe dizziness rapid weight gain fever what is the one additional DANGER SIGN in the first trimester that differentiates it from the second trimester - Answer: sever nausea and vomiting what is different about the focused physical exam for the second and third trimester? - Answer: nothing vitals - BP,P,RR,T weight urine:glucose protein,leukocytes fundal height leopolds FHR fetal movement if a mother with gestational diabetes is on insulin, when do we start the nonstress test on the baby? - Answer: 32 weeks preeclampsia - Answer: a complication of pregnancy characterized by hypertension, edema, and proteinuria preeclampsia risk factors - Answer: prime parity previous preeclamptic pregnancy chronic HTN or chronic renal disease or both Hx of thrombophilia (hypercoagulability) multifetal pregnancy family Hx of preeclampsia t1 or t2 dm obesity systemic lupus erythematosus maternal age <19 or >40 paternal Hx maternal infection/inflammation in current pregnancy in what way is paternal history a risk factor for a birther having preeclampsia - Answer: if the partner previously fathered a preeclamptic pregnancy in another woman Preeclampsia without severe features - Answer: development of mild hypertension with protein uric after 20 weeks gestation diagnostic criteria include BP > 140/90 taken two times at least 4 hours apart urine dipstick reading protein/creatinine ratio > 0.3mg/dL -or- 24-hour urine of > 300 mg protein Preeclampsia with severe features - Answer: *Presence of at least one severe feature:* - BP > 160/110 - Thrombocytopenia - Renal Insufficiency (elevated serum creatinine) - Impaired liver function (elevated liver enzymes) - pulmonary edema - cerebral or visual symptoms - blurred vision, spots, RUQ pain HELLP syndrome - Answer: Hemolysis, Elevated Liver enzymes, Low Platelets A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. Pitocin route of administration - Answer: IV diluted in lactated ringers (IM when IV access is not available) first line medication for postpartum hemorrhage Pitocin contraindications for postpartum hemorrhage - Answer: none Pitocin nursing considerations - Answer: continue to monitor bleeding and uterine tone methergine (methylergometrine) route of administation - Answer: IM second line medication for postpartum hemorrhage methergine (methylergometrine) contraindications for postpartum hemorrhage - Answer: HTN preeclampsia cardiac disease methergine (methylergometrine) nursing considerations - Answer: monitor bleeding and uterine tone do not administer if BP > 140/90 cytotoxic (misoprostol) route of administratoin - Answer: PO, PR second line medication for postpartum hemorrhage cytotoxic (misoprostol) contraindications for postpartum hemorrhage - Answer: none cytotoxic (misoprostol) nursing considerations - Answer: monitor bleeding and uterine tone uterine atony - Answer: inability of the uterus to contract effectively uterine atony risk factors - Answer: overdistention of the uterus due to a large fetus, multiple fetuses, hydramnios, etc. hydramnios (polyhydramnios) - Answer: excessive volume of amniotic fluid (more than 2000ml at term) medical interventions for uterine atony - Answer: firm massage expression of clots emptying the bladder IV oxytocin infusion (contractions) additional uterotonic medications blood, blood products oxygen indwelling urinary catheter bimanual compression manual exploration nursing interventions for uterine atony - Answer: determine source of bleeding if the fundus is boggy , massage it check vital signs estimate blood loss call for help characteristics of postpartum hemorrhage due to lacerations of the genital tract - Answer: bleeding, despite a firm and contracted uterus a slow trickle, oozing, or frank hemorrhage lacerations to the cervix, vagina, and perineum (most common) what are factors that influence PPH due to lacerations? - Answer: operative or precipitous birth