Postpartum Hemorrhage: Final Exam (Comprehensive) -
Questions with Correct Answers
100 questions
1. In the United States, carbetocin is:
A. The only approved uterotonic
B. Required by law at every birth
C. Available only as an oral tablet
D. Not FDA approved, so oxytocin remains the standard prophylactic agent
Correct Answer: D. Not FDA approved, so oxytocin remains the standard prophylactic agent
Rationale: Carbetocin is used in many other countries and recommended by WHO, but US practice relies
on oxytocin. This may change in the future. It is given by injection.
2. Postpartum hemorrhage prevention is described as a shared responsibility of:
A. Only the delivering physician
B. Only the patient
C. The entire maternity team, including nurses, midwives, physicians, anesthesia, and blood bank
D. Only pharmacists
Correct Answer: C. The entire maternity team, including nurses, midwives, physicians,
anesthesia, and blood bank
Rationale: Coordinated teamwork from risk assessment to prophylaxis and monitoring reduces
hemorrhage outcomes. Each role contributes. Prevention is not one person's responsibility.
3. Assessment of the bleeding source should follow the four Ts in which approach?
A. Treating only coagulopathy first
B. Waiting for laboratory results before any examination
C. Checking tone, then inspecting for trauma, then assessing for retained tissue, and evaluating for
coagulopathy
D. Checking only the perineum
Correct Answer: C. Checking tone, then inspecting for trauma, then assessing for retained
tissue, and evaluating for coagulopathy
Rationale: A systematic approach ensures that the most common cause, atony, is addressed while other
causes are considered simultaneously as the team mobilizes. Waiting for labs delays treatment.
,4. Stage 2 hemorrhage in the CMQCC model involves:
A. Normal blood loss
B. Only lochia serosa
C. Continued bleeding with total loss up to 1,500 mL, prompting mobilization of additional help and
blood products
D. Cardiac arrest only
Correct Answer: C. Continued bleeding with total loss up to 1,500 mL, prompting mobilization
of additional help and blood products
Rationale: In Stage 2, teams give additional uterotonics, transfuse based on clinical signs, and consider
procedures such as balloon tamponade, while identifying the cause. Escalation includes notifying the
obstetrician, anesthesia and blood bank.
5. Oxytocin and a second-line uterotonic such as carboprost or methylergonovine:
A. Must never be combined
B. Cancel each other's effects
C. Should be given only after hysterectomy
D. Can be used together, as they act through different mechanisms
Correct Answer: D. Can be used together, as they act through different mechanisms
Rationale: Oxytocin infusion continues while second-line agents are added for refractory atony. They act
on different receptors. They are given early, long before considering surgery.
6. Dinoprostone, a prostaglandin E2 preparation, is sometimes used for atony but should be
avoided in women who are:
A. Hypertensive in all cases
B. Hypotensive, because it can cause vasodilation
C. Breastfeeding
D. Anemic
Correct Answer: B. Hypotensive, because it can cause vasodilation
Rationale: Prostaglandin E2 can lower blood pressure and cause fever, so it is not preferred in
hemodynamically unstable patients. It is used less often than other agents. Breastfeeding and anemia are
not contraindications.
,7. Periurethral and labial lacerations may require repair if they:
A. Are present at all, regardless of bleeding
B. Are less than 1 mm
C. Are not visible
D. Are bleeding or distort anatomy
Correct Answer: D. Are bleeding or distort anatomy
Rationale: Small, nonbleeding periurethral tears may heal without sutures, while bleeding tears need
repair. A catheter may be placed if voiding is difficult. Repair decisions depend on bleeding and anatomy.
8. In trauma-related postpartum hemorrhage, nursing actions while awaiting repair include:
A. Applying direct pressure as directed, monitoring vital signs, and preparing for repair
B. Fundal massage only
C. Encouraging the patient to walk
D. Removing all IV access
Correct Answer: A. Applying direct pressure as directed, monitoring vital signs, and
preparing for repair
Rationale: Direct pressure on bleeding lacerations slows blood loss until repair, while monitoring detects
instability. Massage alone does not stop laceration bleeding. IV access is maintained.
9. A puerperal hematoma most often develops:
A. Within the first 24 hours after birth
B. Several months after birth
C. Before labor
D. Only after cesarean
Correct Answer: A. Within the first 24 hours after birth
Rationale: Most hematomas form soon after delivery from injury to vessels during birth, though some
appear later. Pain and pressure are key symptoms. They often follow vaginal births, including
uncomplicated ones.
, 10. Women who have had placenta accreta managed conservatively and wish for future
pregnancies should be counseled about:
A. No risk in future pregnancies
B. A high risk of recurrence and complications
C. Guaranteed normal placentation
D. The need for no prenatal care
Correct Answer: B. A high risk of recurrence and complications
Rationale: Recurrence of accreta and uterine rupture are concerns, so early ultrasound and specialist
care are needed in future pregnancies. Risk is not eliminated.
11. A patient has heavy bleeding 2 weeks after birth with a tender uterus, fever, and foul lochia.
The likely cause is:
A. Normal lochia
B. Uterine inversion
C. Ovarian torsion
D. Retained products of conception with endometritis
Correct Answer: D. Retained products of conception with endometritis
Rationale: Infection of retained tissue causes secondary PPH, requiring antibiotics and often evacuation
of the uterus. Normal lochia is not foul or heavy at 2 weeks. Inversion occurs at delivery.
12. In placenta accreta, a cesarean incision is often placed:
A. Directly through the placenta
B. Away from the placenta, such as in the upper uterus, to avoid cutting through it
C. Only in the cervix
D. Through the bladder
Correct Answer: B. Away from the placenta, such as in the upper uterus, to avoid cutting
through it
Rationale: Avoiding the placenta allows delivery of the baby with less bleeding, after which the uterus is
closed or removed with the placenta in place. Cutting through the placenta causes massive blood loss.
Questions with Correct Answers
100 questions
1. In the United States, carbetocin is:
A. The only approved uterotonic
B. Required by law at every birth
C. Available only as an oral tablet
D. Not FDA approved, so oxytocin remains the standard prophylactic agent
Correct Answer: D. Not FDA approved, so oxytocin remains the standard prophylactic agent
Rationale: Carbetocin is used in many other countries and recommended by WHO, but US practice relies
on oxytocin. This may change in the future. It is given by injection.
2. Postpartum hemorrhage prevention is described as a shared responsibility of:
A. Only the delivering physician
B. Only the patient
C. The entire maternity team, including nurses, midwives, physicians, anesthesia, and blood bank
D. Only pharmacists
Correct Answer: C. The entire maternity team, including nurses, midwives, physicians,
anesthesia, and blood bank
Rationale: Coordinated teamwork from risk assessment to prophylaxis and monitoring reduces
hemorrhage outcomes. Each role contributes. Prevention is not one person's responsibility.
3. Assessment of the bleeding source should follow the four Ts in which approach?
A. Treating only coagulopathy first
B. Waiting for laboratory results before any examination
C. Checking tone, then inspecting for trauma, then assessing for retained tissue, and evaluating for
coagulopathy
D. Checking only the perineum
Correct Answer: C. Checking tone, then inspecting for trauma, then assessing for retained
tissue, and evaluating for coagulopathy
Rationale: A systematic approach ensures that the most common cause, atony, is addressed while other
causes are considered simultaneously as the team mobilizes. Waiting for labs delays treatment.
,4. Stage 2 hemorrhage in the CMQCC model involves:
A. Normal blood loss
B. Only lochia serosa
C. Continued bleeding with total loss up to 1,500 mL, prompting mobilization of additional help and
blood products
D. Cardiac arrest only
Correct Answer: C. Continued bleeding with total loss up to 1,500 mL, prompting mobilization
of additional help and blood products
Rationale: In Stage 2, teams give additional uterotonics, transfuse based on clinical signs, and consider
procedures such as balloon tamponade, while identifying the cause. Escalation includes notifying the
obstetrician, anesthesia and blood bank.
5. Oxytocin and a second-line uterotonic such as carboprost or methylergonovine:
A. Must never be combined
B. Cancel each other's effects
C. Should be given only after hysterectomy
D. Can be used together, as they act through different mechanisms
Correct Answer: D. Can be used together, as they act through different mechanisms
Rationale: Oxytocin infusion continues while second-line agents are added for refractory atony. They act
on different receptors. They are given early, long before considering surgery.
6. Dinoprostone, a prostaglandin E2 preparation, is sometimes used for atony but should be
avoided in women who are:
A. Hypertensive in all cases
B. Hypotensive, because it can cause vasodilation
C. Breastfeeding
D. Anemic
Correct Answer: B. Hypotensive, because it can cause vasodilation
Rationale: Prostaglandin E2 can lower blood pressure and cause fever, so it is not preferred in
hemodynamically unstable patients. It is used less often than other agents. Breastfeeding and anemia are
not contraindications.
,7. Periurethral and labial lacerations may require repair if they:
A. Are present at all, regardless of bleeding
B. Are less than 1 mm
C. Are not visible
D. Are bleeding or distort anatomy
Correct Answer: D. Are bleeding or distort anatomy
Rationale: Small, nonbleeding periurethral tears may heal without sutures, while bleeding tears need
repair. A catheter may be placed if voiding is difficult. Repair decisions depend on bleeding and anatomy.
8. In trauma-related postpartum hemorrhage, nursing actions while awaiting repair include:
A. Applying direct pressure as directed, monitoring vital signs, and preparing for repair
B. Fundal massage only
C. Encouraging the patient to walk
D. Removing all IV access
Correct Answer: A. Applying direct pressure as directed, monitoring vital signs, and
preparing for repair
Rationale: Direct pressure on bleeding lacerations slows blood loss until repair, while monitoring detects
instability. Massage alone does not stop laceration bleeding. IV access is maintained.
9. A puerperal hematoma most often develops:
A. Within the first 24 hours after birth
B. Several months after birth
C. Before labor
D. Only after cesarean
Correct Answer: A. Within the first 24 hours after birth
Rationale: Most hematomas form soon after delivery from injury to vessels during birth, though some
appear later. Pain and pressure are key symptoms. They often follow vaginal births, including
uncomplicated ones.
, 10. Women who have had placenta accreta managed conservatively and wish for future
pregnancies should be counseled about:
A. No risk in future pregnancies
B. A high risk of recurrence and complications
C. Guaranteed normal placentation
D. The need for no prenatal care
Correct Answer: B. A high risk of recurrence and complications
Rationale: Recurrence of accreta and uterine rupture are concerns, so early ultrasound and specialist
care are needed in future pregnancies. Risk is not eliminated.
11. A patient has heavy bleeding 2 weeks after birth with a tender uterus, fever, and foul lochia.
The likely cause is:
A. Normal lochia
B. Uterine inversion
C. Ovarian torsion
D. Retained products of conception with endometritis
Correct Answer: D. Retained products of conception with endometritis
Rationale: Infection of retained tissue causes secondary PPH, requiring antibiotics and often evacuation
of the uterus. Normal lochia is not foul or heavy at 2 weeks. Inversion occurs at delivery.
12. In placenta accreta, a cesarean incision is often placed:
A. Directly through the placenta
B. Away from the placenta, such as in the upper uterus, to avoid cutting through it
C. Only in the cervix
D. Through the bladder
Correct Answer: B. Away from the placenta, such as in the upper uterus, to avoid cutting
through it
Rationale: Avoiding the placenta allows delivery of the baby with less bleeding, after which the uterus is
closed or removed with the placenta in place. Cutting through the placenta causes massive blood loss.
