TB-Chapter_10__Nursing_Care_of_Women_with_Complications_After_Birth[1] verified

Chapter 10: Nursing Care of Women with Complications After Birth MULTIPLE CHOICE 1. What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output ANS: B Tachycardia is usually the first sign of inadequate blood volume. DIF: Cognitive Level: Knowledge REF: Page 248 OBJ: 2 TOP: Hypovolemic Shock KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction ANS: A Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels. DIF: Cognitive Level: Comprehension REF: Page 250 TOP: Atony KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location. ANS: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm. DIF: Cognitive Level: Application REF: Page 250 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurses next assessment be? a. Fullness of the bladder