Question

Patient data

Answer 1

Correct Answers:

Perform a fundal massage

Rationale :

💎 The assessment findings — boggy, displaced uterus, heavy lochia with large clots, and decreasing blood pressure with elevated heart rate — indicate uterine atony, the leading cause of postpartum hemorrhage (PPH).

💎 A boggy fundus means the uterine muscles are not contracting effectively, allowing excessive bleeding. The displacement to the right side suggests a distended bladder, which interferes with uterine contraction.

💎 The priority nursing action is to perform a firm, gentle fundal massage until the uterus becomes firm, which promotes contraction and minimizes further blood loss.

💎 Once firmness is achieved, the nurse should assist the patient to void or catheterize if necessary, reassess bleeding, and then notify the healthcare provider if bleeding continues.

💎 Immediate intervention is crucial to prevent hypovolemic shock, maintain uterine tone, and safeguard the mother’s recovery.

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Answer 2

Correct Answers:

Fundus slightly boggy and displaced to the right
Heavy bleeding with large clots (-300 mL/hour)
BP decreased to 98/60 mmHg and HR increased to 108 bpm
Feeling lightheaded

Rationale :

💎 Fundus slightly boggy and displaced to the right:

📌A boggy (soft) uterus indicates uterine atony, the most common cause of postpartum hemorrhage (PPH).

📌When the uterus fails to contract effectively after delivery, blood vessels at the placental site remain open, leading to excessive bleeding.

📌Displacement to the right often signifies bladder distension, which interferes with uterine contraction. The nurse should have the patient void or catheterize if unable to urinate.

📌A firm, midline uterus should be expected postpartum; any deviation signals abnormal uterine tone or bladder issues.

💎 Heavy bleeding with large clots (~300 mL/hour):

📌Normal blood loss after a vaginal delivery is ≤500 mL total, not per hour.

📌Losing 300 mL in one hour is considered abnormally high and meets the criteria for early PPH.

📌The presence of large clots suggests retained placental fragments or uterine atony, both of which require immediate intervention such as uterine massage or oxytocin administration.

📌Ongoing heavy bleeding can quickly lead to hypovolemic shock if untreated.

💎 BP decreased to 98/60 mmHg and HR increased to 108 bpm:

📌A drop in blood pressure with a compensatory rise in heart rate is an early sign of hypovolemia due to excessive blood loss.

📌The body increases the heart rate to maintain perfusion as circulating volume decreases.

📌Continuous monitoring of vital signs is crucial in detecting PPH before severe decompensation (e.g., hypotension, tachycardia >120 bpm, pallor, diaphoresis).

📌Immediate actions include notifying the provider, assessing the uterus, and starting IV fluids or uterotonic medications.

💎 Feeling lightheaded:

📌Lightheadedness or dizziness is a subjective symptom of decreased perfusion to the brain caused by blood loss and reduced circulating volume.

📌It indicates the onset of early hypovolemic shock and must be treated as a warning sign of significant hemorrhage.

📌The nurse should assist the client to lie flat, elevate her legs, and initiate emergency postpartum hemorrhage protocol.

📌Prompt recognition prevents progression to syncope or collapse.

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Answer 3

Correct Answers:

Establish or maintain IV access with a large-bore catheter
Administer uterotonic medications per provider order (e.g., oxytocin)
Assess bladder for distention
Monitor vital signs every 5-10 minutes

Rationale :

🩺 Establish or maintain IV access with a large-bore catheter

💥Rapid volume resuscitation is the first priority in suspected PPH; use large-bore (16–18G) access for high-flow crystalloids and potential blood products.

💥Two patent lines are ideal: one for fluids/uterotonics, one kept available for labs/type & cross and blood transfusion if needed.

💥Early aggressive fluids help maintain perfusing blood pressure while definitive uterine control is achieved.

💥Keep warm IV fluids if possible to reduce hypothermia-related coagulopathy.

💊 Administer uterotonic medications per provider order (e.g., oxytocin)

💥After massage, uterotonics are the frontline to treat uterine atony, the most common PPH cause.

💥Start oxytocin promptly (IV infusion or IM). If bleeding persists, anticipate second-line agents:

Methylergonovine (avoid if hypertensive),

Carboprost (15-methyl PGF2α) (avoid in asthma),

Misoprostol (useful where IV access is limited).

💥Timely uterotonics improve uterine tone, compress spiral arteries at the placental site, and reduce blood loss.

💥Continue continuous uterine reassessment; medications work best alongside ongoing massage.

🫙 Assess bladder for distention

💥A full bladder displaces the uterus (often rightward) and prevents firm contraction, worsening atony.

💥Promptly assist to void or perform straight catheterization if unable to void—this often re-centers and firms the fundus.

💥Reassess fundal height/tone immediately after emptying; improvement confirms bladder contribution to atony.

💥Keep a voiding schedule or temporary catheter if repeated distension occurs during stabilization.

📉 Monitor vital signs every 5–10 minutes

💥PPH can deteriorate rapidly; frequent vitals detect early hypovolemia (tachycardia, falling BP, rising RR).

💥Pair vitals with ongoing bleeding quantification (weigh pads/linens, measure clots) and mental-status checks.

💥Escalate care per facility PPH protocol if hemodynamics decline or bleeding remains heavy.

💥Document trends, not just single values—trends guide resuscitation, medication escalation, and transfusion decisions

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Answer 4

Correct Answers:

5 tablets

Rationale :

🔹 Step 1: Dose ordered = 1000 mcg (rectally)

🔹 Step 2: Dose available = 200 mcg per tablet

🔹 Step 3: Formula →

Number of tablets = Dose ordered ÷ Dose available

Number of tablets = 1000 ÷ 200 = 5 tablets

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Answer 5

Correct Answers:

Turn the patient on the left lateral position, apply O2 per mask at 8-10L, turn off pitocin

Rationale :

📌Left lateral position improves uteroplacental perfusion by relieving pressure on the vena cava, enhancing blood flow to the fetus.

📌Oxygen at 8–10 L/min via face mask increases maternal oxygenation and fetal oxygen delivery.

📌Turning off Pitocin (oxytocin) stops uterine stimulation, preventing further fetal distress from uterine hyperstimulation.

📌These actions are appropriate for late decelerations, which reflect uteroplacental insufficiency—a non-reassuring pattern requiring prompt nursing intervention.

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Answer 6

Correct Answers:

Effleurage is a light, circular massage applied to the abdomen to promote relaxation and distract from pain.

Rationale :

✔️Effleurage is a nonpharmacological comfort measure used in early labor.

✔️It involves gentle, rhythmic stroking of the abdomen in circular motions synchronized with breathing.

✔️It works through gate control theory—diverting sensory attention away from pain to soothing tactile stimulation.

✔️Encourages relaxation and maternal focus, reducing tension and perception of pain during contractions.

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Answer 7

Correct Answers:

41113

Rationale :

Twins born at 34 weeks → 1 preterm delivery, 2 living

Son born at 39 weeks → 1 term delivery, 1 living

Spontaneous abortion at 6 weeks → 1 abortion

Current pregnancy → Gravida +1

✅ Correct Answer: G4 T1 P1 A1 L3 → 41113

💎 Rationale:

G (Gravida): 4 total pregnancies (twins, son, miscarriage, current).

T (Term): 1 term delivery (39 weeks).

P (Preterm): 1 preterm (twins at 34 weeks).

A (Abortion): 1 miscarriage at 6 weeks.

L (Living): 3 living children (twins + son).

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Answer 8

Correct Answers:

Cervical changes
Braxton Hicks Contractions
Increased energy level
Bloody Show
Lightening (the relief she can breathe again because the baby is descending)

Rationale :

💠 Cervical changes

📌The cervix begins to soften (ripen), efface (thin), and dilate (open) in preparation for birth.

📌These changes occur due to increased prostaglandin production and pressure from the fetal head.

📌The cervix may move from a posterior to anterior position, indicating readiness for labor.

📌Nurses often assess this using a vaginal exam, confirming the body’s transition from the latent phase toward active labor.

💠 Braxton Hicks contractions

📌These are irregular, painless uterine contractions that occur throughout pregnancy and increase near term.

📌They help tone uterine muscles and promote blood flow to the placenta.

📌Unlike true labor contractions, they do not cause cervical dilation or become progressively stronger or closer together.

📌They often subside with position changes, rest, or hydration, serving as a sign that the uterus is preparing for effective contractions.

💠 Increased energy level (Nesting)

📌Many women experience a burst of energy 24–48 hours before labor known as the “nesting instinct.”

📌This is caused by hormonal changes—especially a rise in adrenaline and drop in progesterone.

📌The pregnant woman may feel the urge to clean, organize, or prepare for the baby, showing the body’s physiological readiness.

📌Nurses should remind mothers to conserve energy, as true labor often begins soon after.

💠 Bloody show

📌The mucus plug that seals the cervical canal during pregnancy is expelled as the cervix begins to efface and dilate.

📌This discharge appears as pink-tinged or blood-streaked mucus, signaling that labor is approaching.

📌It results from capillary rupture in the cervix due to stretching and softening.

📌This is considered a normal sign unless the bleeding becomes heavy or bright red, which could indicate a complication like placenta previa.

💠 Lightening

📌Lightening occurs when the fetal head descends into the maternal pelvis, usually 2–3 weeks before labor in first-time mothers.

📌The mother may feel less shortness of breath as the pressure on the diaphragm decreases.

📌However, she experiences increased urinary frequency and pelvic pressure due to the baby pressing on the bladder.

📌It indicates that the fetus is engaging in the birth canal and the body is preparing for the onset of true labor.

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Answer 9

Correct Answers:

Moderate variability is a reassuring sign of fetal well-being.

Rationale :

💓 Moderate variability = fetal well-being.Moderate variability (6–25 bpm) indicates a well-oxygenated and neurologically intact fetus.

💓 Moderate variability = fetal well-being.Reflects a healthy interplay between sympathetic and parasympathetic nervous systems.

💓 Moderate variability = fetal well-being.It is considered a reassuring baseline pattern in fetal monitoring.

💓 Moderate variability = fetal well-being.Absence or minimal variability may suggest fetal hypoxia, sleep, or medication effects.

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Answer 10

Correct Answers:

Fetus lying on the cord
True knot in the cord
cord around the fetus body or neck

Rationale :

💠 Fetus lying on the cord

♦️When the fetus compresses the umbilical cord by lying or pressing on it, blood flow from the placenta to the fetus temporarily decreases.

♦️This causes variable decelerations, which appear as abrupt drops in the fetal heart rate (FHR) on the monitor.

♦️The compression reduces oxygen and nutrient delivery, triggering a vagal response and slowing the heart rate.

♦️Nursing interventions include repositioning the mother (side to side, knee-chest) to relieve pressure and improve cord perfusion.

💠 True knot in the cord

♦️A true knot occurs when the umbilical cord forms an actual loop that tightens during fetal movement or descent.

♦️The knot can obstruct blood flow intermittently or completely, leading to sudden, variable decelerations in FHR.

♦️This condition is more common in long cords, small fetuses, or highly active pregnancies.

♦️Continuous fetal monitoring is critical; if severe or persistent, emergency delivery may be needed to prevent hypoxia or stillbirth.

💠 Cord around the fetus’ body or neck (Nuchal cord)

♦️A nuchal cord refers to the umbilical cord wrapped around the fetal neck or sometimes looped around the trunk or limbs.

♦️As the fetus moves or during contractions, the cord can tighten, compressing vessels and causing variable decelerations.

♦️These decelerations are typically abrupt, variable in shape and timing, and resolve when the compression is relieved.

♦️Nursing interventions include changing maternal position, administering oxygen, and discontinuing oxytocin if running, to reduce stress on the fetus.

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QLexNursing

1 :
Patient data

Answer Options

2 :
Patient data

Answer Options

3 :
Patient data

Answer Options

4 :
A client has just delivered and is experiencing bleeding. The doctor has ordered misoprostol 1000 mcg to be administered rectally. Available is misoprostol 200 mcg tablets How many tablets would be administered? 1

5 :
What nursing action would the nurse take with the deceleration being depicted?

6 :
A laboring patient is requesting comfort measures to help manage pain during the early stages of labor. The nurse suggests using effleurage. Which of the following statements best describes the purpose of effleurage during labor?

8 :
What are the premonitory signs of labor? Select all that apply

9 :
A nurse is assessing the fetal heart rate (FHR) of a laboring patient and notes moderate variability. What is the most appropriate interpretation of this finding?

10 :
What are the causes of variable decelerations? Select all that apply

QLexNursing

1 : Patient data

Answer Options

2 : Patient data

Answer Options

3 : Patient data

Answer Options

4 : A client has just delivered and is experiencing bleeding. The doctor has ordered misoprostol 1000 mcg to be administered rectally. Available is misoprostol 200 mcg tablets How many tablets would be administered? 1

5 : What nursing action would the nurse take with the deceleration being depicted?

6 : A laboring patient is requesting comfort measures to help manage pain during the early stages of labor. The nurse suggests using effleurage. Which of the following statements best describes the purpose of effleurage during labor?

8 : What are the premonitory signs of labor? Select all that apply

9 : A nurse is assessing the fetal heart rate (FHR) of a laboring patient and notes moderate variability. What is the most appropriate interpretation of this finding?

10 : What are the causes of variable decelerations? Select all that apply

1 :
Patient data

2 :
Patient data

3 :
Patient data

4 :
A client has just delivered and is experiencing bleeding. The doctor has ordered misoprostol 1000 mcg to be administered rectally. Available is misoprostol 200 mcg tablets How many tablets would be administered? 1

5 :
What nursing action would the nurse take with the deceleration being depicted?

6 :
A laboring patient is requesting comfort measures to help manage pain during the early stages of labor. The nurse suggests using effleurage. Which of the following statements best describes the purpose of effleurage during labor?

8 :
What are the premonitory signs of labor? Select all that apply

9 :
A nurse is assessing the fetal heart rate (FHR) of a laboring patient and notes moderate variability. What is the most appropriate interpretation of this finding?

10 :
What are the causes of variable decelerations? Select all that apply