Solutions Manual for Maternity
Newborn and Women's Health Nursing
2nd Edition by OMeara
ISBN: 9781975209025
Suggested Answers to Assignments, Chapter 1,
Bess Gaskell: Immediate Postpartum Hemorrhage
Written Assignment Learning
Objective(s)
1. Students’ answers should include the following:
• Second trimester prenatal screening:
o Prenatal visit once a month
o Detection and rate of fetal heartbeat
o Weight gain 1/2 to 1 pound per week
o Possible maternal serum alpha-fetoprotein (MSAFP)
o Fetal survey ultrasound
o Oral glucose screen
o Hemoglobin and hematocrit level
• There are several roles of the nurse such as the health professional, educator, and advocate
Group Assignment
1a. Students’ answers should include the following:
Identification of risk factors for early postpartum hemorrhage:
• Retained placenta
5, 6
Learning
Objective(s)
• Placenta accreta 1, 2
Group Assignment Learning
Objective(s)
• Failure to progress in second stage of labor and birth
• Lacerations of cervix, vagina, or vulva
• Large for gestational-age-infant
• Hypertensive disorders
• Induction or augmentation of labor with oxytocin (Pitocin)
• Instrumental births (e.g., forceps or vacuum suction)
1b. Students’ answer should include three measures with rationales to manage postpartum hemorrhage such as:
• Give oxytocin (Pitocin) after the placenta is delivered.
o To aid in uterine contraction to constrict open blood vessels where the placenta separated from the uterus
• Massage uterine fundus.
o To facilitate uterine contractions to close open blood vessels from placenta separation whereby preventing blood loss.
• Assist medical team to perform D&C
o To remove any retained placenta fragments.
• Facilitate medical team to apply tamponade.
o To put pressure over open blood vessels to stop bleeding.
• Prepare patient for emergency hysterectomy
o As a last resort, the medical team may need to perform a hysterectomy to stop hemorrhage and save the patient’s life.
Clinical Assignments Learning
1. Students’ answers should include the following:
• Normal fetal monitoring patterns: accelerations, variability, and early decelerations
• Abnormal fetal monitoring patterns: late decelerations and variable decelerations
2. Students’ answers should include the following:
• First trimester (0 to 13 weeks):
o Initial prenatal health history
o First prenatal physical exam
o Body mass index (BMI) and recommended weight gain of 1 to 5 pounds
o Testing for congenital defects (PAPP-A and hCG) and ultrasound
o Routine first trimester labs
o Ultrasound between 11 and 13 weeks
• Second trimester (14 to 23 weeks):
o Prenatal visits
o Weight gain 1 pound per week
o Testing for congenital defects (MSAFP) and if elevated amniocentesis; fetal survey ultrasound
o Oral glucose screen
o Hemoglobin and hematocrit level
• Third trimester (24 to 40 weeks):
o Prenatal visits
o Weight gain 1 pound per week
o Ultrasound to determine placenta placement and
4
5
Clinical Assignments Learning
Objective
cervix changes
o Nonstress tests: uterine contractions and fetal patterns of accelerations, late decelerations, variability, and any abnormal patterns
o Biophysical profiles (BPP)
o Group B Streptococcus vaginal culture
Web Assignment
1. Students’ answers should include the following:
• Example of a reputable website:
https://www.mayoclinic.org/diseases-conditions/placentalabruption/symptoms-causes/syc-20376458
• To prevent placental abruption:
o Encourage to-be and patients who are expecting to cut down and quit nicotine use.
o Discourage use of cocaine during pregnancy.
o Manage blood pressure throughout pregnancy
o Identify intrauterine infections promptly.
o Seek emergent care if the patient is in a motor vehicle collision (wear seat belt), falls, or is a victim of intimate partner violence (IPV).
o Consult OB prior to next pregnancy if there is a history of placental abruption.
• Recognize signs of placental abruption, such as: 3
Web Assignment Learning
Objective
o Abdominal pain or uterine discomfort
o Firm or board-like abdomen or uterus
o Uterine contractions
o Back pain
o Vaginal bleeding that varies from light to heavy (note that with concealed abruption vaginal bleeding is absent)
o Nonreassuring fetal patterns
o Maternal hypovolemic shock
Suggested Answers to Case Study, Chapter 1, Bess
Gaskell: Immediate Postpartum Hemorrhage
Note: The answers presented here are for a supplemental case study to this chapter and feature different individual(s) than the case study in the chapter.
1. First, the nurse needs to tell Morgan that the hemorrhage is not her fault. Although some risk factors for postpartum hemorrhage are modifiable, meaning they can be changed (like her weight), others that are nonmodifiable (such as multiparity, age, and retained placenta) cannot. Because many of Morgan’s risk factors were nonmodifiable, the hemorrhage was out of Morgan’s control. The nurse could explain that Morgan’s weight and the fact that she is continuing to consider additional pregnancies may be factors that could possibly contribute to a future postpartum hemorrhage. The nurse should also encourage Morgan to dialogue and seek guidance from her care provider about risks that can be modified (as well as those that cannot) to help avoid the risk of hemorrhage if she becomes pregnant again.
2. The postpartum nurse will spend a great deal of time with the recovering patient. The nurse should:
• be available to the patient for questions.
• encourage the patient to discuss her feelings (i.e., “Tell me your concerns,” “Let’s talk about your fears”)
• recognize and validate the patient’s fears/concerns as real.
• offer support from other members of the healthcare team (social service, clergy, physician).
Suggested Answers to Discussion Topics, Chapter 1, Bess Gaskill: Immediate Postpartum
Hemorrhage
Suggested Answers to Discussion Topics Learning
Objective(s)
1a. Students’ answers should include the following:
• Rachel is underweight with a BMI of 17.8 (less than 18.5).
• A 10-lb (4.5 kg) weight gain at 16 weeks and 5 days of pregnancy is normal.
• Instruct Rachel to take prenatal vitamins daily.
1b. Students’ answers should include the following:
• Laboratory tests needed during the first prenatal office visit include:
o Blood type and screen
o Complete blood count
o Rubella
o Hepatitis B virus
o Syphilis
o Gonorrhea and chlamydia
o Human immunodeficiency virus
o Urine dip (glucose, protein, ketones, nitrites, leukocytes, and blood)
• During the next appointment, a fetal survey ultrasound will be 5
Suggested Answers to Discussion Topics Learning
Objective(s) performed.
2a. Students’ answers should include the following:
• Immediate management of early postpartum hemorrhage involves the following priority actions:
o Implement uterine fundal massage for 10 to 15 minutes
o Give fentanyl, misoprostol, or methylergonovine per hospital protocol.
o Obtain maternal vital signs every 5 minutes until the patient stabilizes.
o Apply oxygen per non-rebreather mask at 10 L/min.
o Notify medical team in preparation for D&C, balloon tamponade, or laceration repair.
2b. Students’ answers should include the following:
• Notation of risk factors for early postpartum hemorrhage:
o Failure to progress in second stage of labor
o Augmentation of labor with oxytocin
o Large-for-gestational-age infant
o Use of vacuum to assist with vaginal birth
3a. Students’ answers should include the following:
• The nurse makes the interpretation that the patient is at risk for placental abruption. Risk factors for placental abruption for this situation include: 3, 4, 6
Suggested Answers to Discussion Topics Learning
Objective(s)
o Advanced maternal age
o Maternal cigarette smoking
o Cocaine use
• Relevant signs for placental abruption include:
o Absent vaginal bleeding, due to concealed blood behind the placenta
o Uterine tenderness
o Incomplete relaxation between uterine contractions
o Nonreassuring fetal heart rate pattern; lack of variability
o Hard or board-like maternal abdomen
3b. Students’ answers should include the following:
• When the patient asks if she is going to die, the nurse should respond as follows:
o “What you are expressing sounds like you are scared or afraid of dying ”
o The nurse should state they are not going to abandon the patient.
o The nurse should take actions to bring maternal blood pressure down and to make the patient as comfortable as possible without giving pain medications
• In response to the patient asking for information about the fetus, the nurse should respond as follows:
o “The baby has a heartbeat of 120 to 125, so I’m going to
Suggested Answers to Discussion Topics Learning
Objective(s)
put a non-rebreather mask with oxygen on you, so the baby can get more oxygen.”
o The nurse should communicate information that is factual and not give false reassurance.
3c. Students’ answers should include the following:
• Measures that can assist the nurse in coping to give successful patient care may include expressing feelings to a colleague, seeking faithbased support, meditating, and debriefing after providing nursing care during a difficult situation
• The role of the nurse is to ensure that the patient gets the best nursing care during labor and birth; however, once the infant is born, hospital policy and protocol for possible substance abuse would need to be carried out (e.g., test umbilical cord and/or infant’s urine for illegal substance[s]).
• If the nurse is unable to provide nonjudgmental care, the nurse needs to recognize that and remove themselves by asking the lead/charge nurse to be reassigned.
Answers to Think Critically Questions, Chapter 1, Bess
Gaskell: Immediate Postpartum Hemorrhage
1. Common side effects of the nonhormonal intrauterine device include a longer, heavier, crampier menses, particularly for the first six months of use.
2. Bess’s risk factors for immediate postpartum hemorrhage include retained placenta and induction of contraction with oxytocin.
3. Signs and symptoms of hypovolemic shock include the following:
o Change in mental status (restlessness or trouble with concentration)
o Decreased (<30 mL/h) urinary output
o Thready (weak) pulse
o Decreased pulse rate
o Increased respiratory rate
o Decreased blood pressure (a late sign)
o Cool, moist, pale skin
o Decreasing hemoglobin and hematocrit
4. Care considerations for methylergonovine:
o Should never be used prior to birth of fetus because of potential for very strong, prolonged contractions.
o If used in third stage, obstetric provider should be directly supervising.
o Smoking strongly is discouraged because of vasoconstrictive properties of medication
o Monitor for appropriate uterine firmness, fundal height, and lochia
o Patient may have very strong cramping Care Considerations for oxytocin:
o Continuous fetal and contraction monitoring is required and should be reviewed every 15 minutes and with every change in dose. Fetal monitoring should be every 5 minutes during active pushing.
o Maternal heart rate, blood pressure, and respirations should be monitored every half an hour to an hour and with dose changes.
o Urine output should be at least 120 mL every 4 hours.
o Intravenous intake should not exceed 1,000 mL in 8 hours.
Though oxytocin is commonly used to induce and augment labor, methylergonovine is used exclusively after birth of the infant. Whereas nurses routinely monitor oxytocin, the obstetric provider must directly supervise a patient receiving methylergonovine. When used after the birth, the uterus is monitored during the use of both medications for firmness, fundal height, and lochia. Both agents can cause strong uterine cramping.
5. Newborn reflexes mentioned in this chapter include the rooting reflex and the grasp reflex. The Moro reflex looks like “baby jazz hands.”
Assignments, Chapter 1, Bess Gaskell: Immediate Postpartum Hemorrhage
Written Assignment
1. Write a short essay that describes several prenatal screening tests for patients in their second trimester of pregnancy. In your answer, note at least two roles of the nurse with an example of performing that role during a prenatal visit.
Learning
Objective(s)
5, 6
Group Assignment
1. Divide into small groups of four or five students:
a. Discuss the identification of risk factors for early postpartum hemorrhage.
b. List three nursing interventions and provide rationales for each.
Clinical Assignments
Learning
Objective(s)
1, 2
Learning Objective
1. Explain the meaning of fetal monitoring pattern(s) that were displayed during your clinical day. 4
2. Outline key prenatal screening results that were carried out for each trimester of a patient during 5
Clinical Assignments
Learning Objective your clinical experience.
Web Assignment
Learning Objective
1. Design a teaching plan based on one reputable website to educate a group of high-risk obstetrical patients on how to prevent placental abruption and to recognize signs of placental abruption. 3
Case Study, Chapter 1, Bess Gaskell: Immediate Postpartum Hemorrhage
Note: The case study presented here is a supplemental case to this chapter and features different individual(s).
Morgan Logan is a 37-year-old single mother of five who just gave birth to her sixth baby. She did not know she was pregnant because she was busy working and caring for her five young children at home. Additionally, she is moderately obese and thought she was just putting on more weight. Morgan did not seek medical care until her last trimester. Her labor was uneventful, but at birth, the doctor was concerned that there may have been a small piece of the placenta that was retained. The doctor encouraged the nurses in the postpartum unit to keep a close eye on Morgan and to report if any significant issues regarding her postpartum stay. Four hours after arriving on the maternity floor, Morgan felt “a huge gush of blood when she stood up.” She passed a clot the size of an orange. The nurse massaged her fundus and called the doctor immediately. The hemorrhage was controlled, and no further issues were noted. The day after birth, Morgan remained perplexed as to why she began to hemorrhage. She blames herself and her busy lifestyle and is feeling terrible about putting herself, the family, and most importantly her newborn at risk. (Learning Objectives #1 and #6)
1. Morgan asks the nurse what she could have done differently, or what she could do in the future, to prevent a postpartum hemorrhage. How should the nurse answer Morgan’s questions about postpartum hemorrhage and preventative measures?
2. Identify some ways that the postpartum nurse can help Morgan most effectively cope with her current hospital experience.
Discussion Topics, Chapter 1, Bess Gaskell: Immediate Postpartum Hemorrhage
Discussion Topics Learning
Objective(s)
1. Rachel arrives to her first appointment at the freestanding prenatal clinic on October 30. She reports her last menstrual period started July 4, and she believes that she is pregnant. Her prepregnant weight was 85 lb (38.5 kg). Her current weight is 95 lb (43 kg), and her height is 4 feet, 10 inches.
a. Based on the first prenatal visit biometric data, what would the nurse teach Rachel about prenatal nutrition?
b. What are the laboratory tests that the nurse needs to obtain during this prenatal visit and at her next appointment?
2. Lucy, who is 16 years of age, arrives in the postpartum unit. The labor and delivery nurse gives you the following hand-off report: labor was augmented during the second stage after 3.5 hours of labor; she gave birth to a 9-lb, 4-oz (4.19 kg) baby boy one hour ago with vacuum suction assistance; uterine fundus is firm at U/3; moderate, rubra lochia.
a. Upon transfer, the nurse performs an initial assessment: uterine fundus boggy at U/2 and heavy lochia with clots the size of plums. What are the priority nursing actions that the nurse carries out?
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1, 2
Discussion Topics Learning
Objective(s)
b. What are the risk factors for postpartum hemorrhage that the nurse notes from Lucy’s hand-off report?
3. Amy is a 35-year-old that arrives in the labor and delivery unit by ambulance with severe, board-like abdominal pain. She reports being pregnant at 32 weeks’ gestation. An electronic monitor reveals a continuous uterine contraction by an elevated baseline, and the fetal heart rate is steady at 120 to 125 beats/min, with no accelerations and no decelerations. The nurse notes there is no vaginal bleeding. Amy’s vital signs are temperature 99.2°F (37.8°C), blood pressure 168/110 mm Hg, heart rate 118 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 95%. The paramedic noted that the patient had cocaine paraphernalia and cigarettes on her when the paramedic arrived.
a. What interpretation of the situation, supported by identification of relevant risk factors and signs, does the nurse make?
b. Considering the electronic monitoring data and maternal vital signs, what explanation would the nurse give to this patient when she asks, “Am I going to die?” and “Is my baby going to be alright?”
c. What are some measures that the nurse can take to cope with judgmental thoughts about this situation? What is the nurse’s role to provide nursing care for this pregnant patient and to advocate
3, 4, 6
Discussion Topics Learning
Objective(s) for the fetus?