Question

A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make

Answer 1

Correct Answers:

"The most accurate indication of organ perfusion is a client's urine output."

Rationale :

💠 Urine output directly reflects renal perfusion, which closely mirrors overall organ perfusion during shock states.

💠 In postpartum hemorrhagic shock, maintaining urine output ≥ 30 mL/hr indicates adequate circulating volume and tissue oxygenation.

💠 Vital signs can be temporarily compensated in young/postpartum clients, making urine output a more reliable early indicator.

💠 Oliguria is an early warning sign of inadequate perfusion and impending organ dysfunction.

💠 Continuous urine monitoring guides fluid resuscitation effectiveness and ongoing management.

“Manifestations of shock might not appear until a client loses 20% of their blood volume.”

💠 Clinical signs of shock can appear with as little as 10–15% blood loss, especially if rapid.

💠 Waiting for 20% loss may delay recognition and treatment.

“Hemorrhagic shock will cause an increase in a client’s serum pH level.”

💠 Hemorrhagic shock causes metabolic acidosis due to lactic acid buildup, lowering pH, not increasing it.

💠 Decreased perfusion leads to anaerobic metabolism.

“An infusion of 1 mL of lactated Ringer’s is given for each 1 mL of blood loss.”

💠 Crystalloid replacement typically follows a 3:1 rule (≈ 3 mL crystalloid per 1 mL blood loss).

💠 A 1:1 ratio is insufficient for intravascular volume restoration.

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Answer 2

Correct Answers

Blank 1 Correct Option: fundal tone
Blank 2 Correct Option: heart rate

Rationale :

Fundal tone

💠 A boggy uterus that does not firm with massage indicates uterine atony, the most common cause of postpartum hemorrhage.

💠 The client has multiple high-risk factors: prolonged labor, forceps-assisted delivery, large newborn (macrosomia), and manual removal of placental fragments.

💠 Heavy lochia with large clots confirms ongoing uterine bleeding related to poor uterine contraction.

💠 Assessing fundal tone first addresses the source of bleeding and guides immediate lifesaving interventions (uterine massage, uterotonics).

💠 This follows cause-first priority nursing judgment in postpartum hemorrhage.

Heart rate

💠 Tachycardia (HR 100/min) is an early and sensitive indicator of hypovolemic shock.

💠 Blood pressure may remain normal initially due to physiologic compensation, especially postpartum.

💠 Monitoring heart rate provides real-time assessment of circulatory status and blood loss severity.

💠 Rising heart rate signals worsening hemorrhage and inadequate perfusion.

💠 This supports rapid escalation of care to prevent hemorrhagic shock.

Pain level

💠 Pain is important but not life-threatening in the presence of active hemorrhage.

Bruising to perineal area

💠 Ecchymosis suggests trauma or hematoma but does not explain massive uterine bleeding.

Uterine height

💠 Height helps trend involution, but tone determines bleeding control.

Temperature

💠 Fever assessment is secondary and not urgent during active hemorrhage.

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Answer 3

Correct Answers

Blank 1 Correct Option: postpartum hemorrhage
Blank 2 Correct Option: urinary tract infection

Rationale :

Postpartum hemorrhage

💠 Boggy fundus that is elevated and deviated to the right indicates uterine atony caused by bladder distention, a major risk factor for hemorrhage.

💠 The client had saturated perineal pads and heavy lochia, signaling ongoing blood loss.

💠 Tachycardia (HR 110/min) with borderline hypotension suggests early hypovolemia.

💠 Low Hgb (10 g/dL) and Hct (30%) indicate reduced oxygen-carrying capacity, increasing hemorrhage risk.

💠 Prompt bladder emptying (700 mL returned) confirms urinary retention contributing to uterine atony.

Urinary tract infection

💠 Urinary retention and straining to void increase the risk of bacterial growth.

💠 Straight catheterization introduces a break in sterile defenses, elevating UTI risk.

💠 Pink-tinged urine may reflect irritation or trauma, warranting close monitoring.

💠 Postoperative status and reduced mobility further increase infection susceptibility.

💠 Early identification supports preventive measures and timely treatment.

Why the other options are not most likely

💠Uterine inversion: No evidence of uterine protrusion or acute shock.

💠Endometritis / Postpartum infection: Temperature is below febrile range; WBC is normal.

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Answer 4

Correct Answers:

Obtain prescription for a broad-spectrum antibiotic.

Rationale :

💠 Foul-smelling lochia, uterine tenderness, fever, and chills are classic findings of postpartum endometritis, a serious uterine infection.

💠 The client has major risk factors including prolonged rupture of membranes and internal fetal monitoring, which increase bacterial entry into the uterus.

💠 Rising temperature (38.9°C / 102°F) and tachycardia indicate a worsening infectious process requiring prompt treatment.

💠 Broad-spectrum IV antibiotics are the first-line treatment to prevent progression to sepsis or septic shock.

💠 Early antibiotic therapy is critical to ensure maternal safety and recovery.

Instruct the client to stop breastfeeding.

💠 Breastfeeding is not contraindicated with most antibiotics used to treat endometritis.

💠 Stopping breastfeeding does not address the underlying infection.

Initiate airborne isolation precautions.

💠 Endometritis is caused by endogenous vaginal flora, not airborne pathogens.

💠 Standard precautions are sufficient.

Place the client on strict bedrest.

💠 Bedrest does not treat infection and increases the risk of thromboembolism.

💠 Treatment must focus on eradication of the infection.

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Answer 5

Correct Answers:

Heart rate 132/min

Rationale :

💠 Terbutaline is a beta-adrenergic agonist that commonly causes maternal tachycardia, which can become dangerous.

💠 A heart rate of 132/min indicates significant cardiovascular stimulation and increases the risk of dysrhythmias and myocardial stress.

💠 Tachycardia is the most serious adverse effect associated with terbutaline and requires immediate provider notification.

💠 Continued dosing in the presence of marked tachycardia can lead to hypotension, chest pain, or pulmonary edema.

💠 Maternal safety takes priority because compromised maternal cardiac status also affects fetal perfusion.

Report of headache

💠 Headache is a common, non-life-threatening side effect of beta-agonists.

💠 It does not require urgent intervention unless severe or persistent.

Nasal congestion

💠 Nasal congestion is a mild vasodilatory effect.

💠 This finding is not clinically urgent.

Tremors

💠 Tremors are an expected side effect of terbutaline due to beta-adrenergic stimulation.

💠 They are uncomfortable but not dangerous.

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Answer 6

Correct Answers:

Epigastric pain

Rationale :

💠 Epigastric pain in the third trimester is a warning sign of preeclampsia, particularly severe features related to liver involvement.

💠 This pain may indicate hepatic swelling or capsular stretching, which can precede eclampsia or HELLP syndrome.

💠 Preeclampsia can progress rapidly and lead to maternal seizures, stroke, or placental insufficiency.

💠 Any report of epigastric or right upper quadrant pain requires immediate provider notification.

💠 Early recognition is critical to protect both maternal and fetal safety.

Leukorrhea

💠 Increased vaginal discharge is a normal physiologic change in pregnancy.

💠 It results from estrogen stimulation and does not indicate pathology.

Excessive salivation

💠 Ptyalism can occur during pregnancy due to hormonal changes.

💠 It is uncomfortable but not dangerous.

Darkening of the skin on the face

💠 Facial hyperpigmentation (melasma/chloasma) is a common, expected finding.

💠 It is caused by increased melanocyte-stimulating hormone.

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Answer 7

Correct Answers

Abdominal Ultrasound [ Anticipated ]
Administration of IV fluids [ Anticipated ]
Administration of betamethasone [ Anticipated ]
Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies [ Anticipated ]
Digital cervical exam to assess dilation and effacement [ Contraindicated ]
Digital cervical exam to assess dilation and effacement [ Contraindicated ]
Placement of an internal fetal spiral electrode [ Contraindicated ]
Continuous monitoring of FHR [ Anticipated ]

Rationale :

Abdominal ultrasound → Anticipated

💠 Ultrasound is the diagnostic test of choice to identify placental location.

💠 It is noninvasive and safe in the setting of antepartum bleeding.

💠 Required before any cervical or vaginal examination.

💠 Helps confirm or rule out placenta previa vs abruption.

💠 Guides further management and delivery planning.

Administration of IV fluids → Anticipated

💠 Ongoing bleeding places the client at risk for hypovolemia.

💠 IV fluids support circulatory volume and uteroplacental perfusion.

💠 Prevents progression to maternal shock.

💠 Allows rapid access if blood products are needed.

💠 This is standard supportive care in antepartum bleeding.

Administration of betamethasone → Anticipated

💠 Client is 30 weeks gestation, at risk for preterm delivery.

💠 Betamethasone promotes fetal lung maturity.

💠 Recommended when preterm birth is a possibility within 7 days.

💠 Reduces neonatal RDS, IVH, and NEC.

💠 Appropriate even while awaiting definitive diagnosis.

Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies → Anticipated

💠 CBC evaluates hemoglobin/hematocrit for blood loss.

💠 Blood type & Rh needed for possible transfusion and Rh-Ig if Rh-negative.

💠 Coagulation studies assess for bleeding complications.

💠 Establishes baseline values for ongoing monitoring.

💠 Standard of care in significant antepartum bleeding.

Digital cervical exam to assess dilation and effacement → Contraindicated

💠 Absolutely contraindicated with suspected placenta previa.

💠 Digital exam can disrupt placental attachment.

💠 May cause massive hemorrhage.

💠 Cervical assessment is deferred until placenta location is confirmed.

💠 This is a high-risk, unsafe intervention in this scenario.

Placement of an internal fetal spiral electrode → Contraindicated

💠 Requires ruptured membranes and cervical dilation.

💠 Invasive and increases risk of hemorrhage and infection.

💠 Contraindicated with antepartum bleeding of unknown cause.

💠 External monitoring is sufficient and safer.

💠 Should not be used until placenta previa is ruled out.

Continuous monitoring of FHR → Anticipated

💠 Ongoing bleeding places fetus at risk for hypoxia.

💠 Continuous monitoring evaluates fetal well-being in real time.

💠 Allows early detection of fetal distress.

💠 Noninvasive and safe.

💠 Standard intervention in antepartum hemorrhage

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Answer 8

Correct Answers:

A client who has an indwelling urinary catheter

Rationale :

💠 Indwelling urinary catheters increase fall risk due to restricted mobility and tubing entanglement when the client attempts to ambulate.

💠 Postpartum clients may have residual effects of anesthesia or analgesics, compounding instability during movement.

💠 Catheter bags and lines can catch on bedrails or furniture, leading to tripping.

💠 Clients may rush to move because they don’t feel the urge to void, reducing caution.

💠 Fall-prevention protocols emphasize assisted ambulation for clients with catheters.

A client who has a second-degree perineal laceration

💠 Perineal discomfort can limit movement but does not inherently increase fall risk.

💠 With assistance and pain control, ambulation is generally safe.

A client who is saturating a perineal pad every 5 to 6 hr

💠 This amount of lochia can be within expected limits postpartum.

💠 It does not directly impair balance or mobility.

A client who is experiencing breast engorgement

💠 Engorgement causes discomfort but does not affect gait or balance.

💠 It is not associated with orthostatic changes or mobility hazards.

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Answer 9

Correct Answers:

Heart rate 54/min

Rationale :

💠 Labetalol is a beta-adrenergic blocker that lowers heart rate and blood pressure.

💠 A heart rate of 54/min indicates bradycardia, which is a contraindication to administering beta-blockers.

💠 Giving labetalol in this situation can cause severe bradycardia, hypotension, and decreased cardiac output.

💠 Maternal bradycardia can also compromise uteroplacental perfusion, affecting fetal oxygenation.

💠 The nurse should withhold the medication and notify the provider immediately.

Uric acid 7.5 mg/dL

💠 Mildly elevated uric acid is expected in preeclampsia.

💠 It does not contraindicate antihypertensive therapy.

FHR 112/min

💠 A fetal heart rate of 110–160/min is normal.

💠 This finding does not require withholding labetalol.

BUN 23 mg/dL

💠 Slightly elevated BUN can occur with preeclampsia-related renal changes.

💠 This level alone does not prevent labetalol administration.

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Answer 10

Correct Answers

Blank 1 Correct Option: Ectopic pregnancy
Blank 2 Correct Option: Anticipate a prescription for intramuscular methotrexate and Obtain blood for CBC and liver function tests
Blank 3 Correct Option: Referred shoulder pain and Hypotension

Rationale :

Anticipate a prescription for intramuscular methotrexate

💠 Methotrexate is used to treat ectopic pregnancy by stopping the growth of the embryo.

💠 This is the standard non-surgical treatment when the pregnancy is not advanced, and there is no risk of rupture.

Obtain blood for CBC and liver function tests

💠 CBC is necessary to assess for blood loss and any potential signs of infection.

💠 Liver function tests help assess the health of the liver, especially if methotrexate is administered, as it can affect liver function.

Parameters to Monitor:

Referred shoulder pain

💠 Shoulder pain is often a sign of internal bleeding or rupture in ectopic pregnancy.

💠 It indicates peritoneal irritation due to blood accumulation in the abdominal cavity.

Hypotension

💠 Hypotension indicates blood loss, a life-threatening complication of ectopic pregnancy, especially if rupture occurs.

💠 Monitoring blood pressure is essential to detect shock early.

💠The client's symptoms—vaginal bleeding, dull left lower quadrant pain, and positive hCG levels with an empty uterus on ultrasound—suggest an ectopic pregnancy. This occurs when the embryo implants outside the uterine cavity, most commonly in the fallopian tube.

💠The treatment options for ectopic pregnancy include methotrexate if the pregnancy is not ruptured and the condition is stable, or surgical intervention if necessary.

💠Monitoring for complications like shoulder pain and hypotension is critical in detecting a ruptured ectopic pregnancy, which can cause severe bleeding and is a medical emergency.

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Assessment

No.

1 :
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make

2 :
A nurse is caring for a client who is in the fourth stage of labor.

Correct Answers

3 :
A nurse is caring for a client following an emergency cesarean birth.

Correct Answers

4 :
A nurse is caring for a client who is 3 days postpartum.

Answer Options

5 :
A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

6 :
A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

7 :
A nurse on an antepartum unit is caring for a client.

Correct Answers

8 :
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

9 :
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?

10 :
A nurse is caring for a client in the emergency department.

Correct Answers

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Potential intervention	Anticipated	Contraindicated
Abdominal Ultrasound
Administration of IV fluids
Administration of betamethasone
Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies
Digital cervical exam to assess dilation and effacement
Digital cervical exam to assess dilation and effacement
Placement of an internal fetal spiral electrode
Continuous monitoring of FHR

Assessment

No.

1 : A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make

2 : A nurse is caring for a client who is in the fourth stage of labor.

Correct Answers

3 : A nurse is caring for a client following an emergency cesarean birth.

Correct Answers

4 : A nurse is caring for a client who is 3 days postpartum.

Answer Options

5 : A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

6 : A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

7 : A nurse on an antepartum unit is caring for a client.

Correct Answers

8 : A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

9 : A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?

10 : A nurse is caring for a client in the emergency department.

Correct Answers

1 :
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make

2 :
A nurse is caring for a client who is in the fourth stage of labor.

3 :
A nurse is caring for a client following an emergency cesarean birth.

4 :
A nurse is caring for a client who is 3 days postpartum.

5 :
A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

6 :
A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

7 :
A nurse on an antepartum unit is caring for a client.

8 :
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

9 :
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?

10 :
A nurse is caring for a client in the emergency department.