11.7 Learning Activities

Postpartum Hemorrhage Case Study^[1]

Use the following information to answer questions 1-6.

Handoff Report:

1200: This is Maria Hernandez, a 42-year-old female, G3P3, who experienced a vaginal delivery three hours ago with no difficulty removing the placenta.  She is a full code, has an allergy to penicillin and is positive for gestational diabetes.  She is experiencing a postpartum hemorrhage. Her uterus remains boggy, and she has had an excessive amount of bright red blood loss despite interventions.  Her skin is pale and clammy. Most recent vital signs are blood pressure of 80/50 mmHg, heart rate of 122 bpm, respirations 24 breaths per minute, and temperature of 98.4 degrees F. IV access is established, and she has two 18-gauge IVs in place.  We are continuing to run fluids.  Please continue to monitor closely for further deterioration and prepare for possible blood transfusion and operating room if her condition does not improve with the current interventions.  Her family is present at the bedside and quite distraught.

Progress Notes:

• 01/08/2024 09:00 – Client delivered vaginally.  Fundus firm and at midline.  No signs of hemorrhage.
• 01/08/2024 10:30 – Client reported feeling lightheaded.  BP 98/60, HR 100.  Encouraged to drink fluids.
• 01/08/2024 11:00 – Client reported feeling worse.  Fundus boggy, bleeding noted to be excessive.  Provider notified and orders given for oxytocin. One dose of oxytocin given.
• 01/08/2024 11:15 – Client continues to bleed.  Fundus remains boggy.  Second nurse called to bedside for assistance.
• 01/08/2024 11:30 – Client becoming increasingly pale with cool and clammy skin.  BP 85/50, HR 115.  IV fluids started per order.  Client placed on oxygen.
• 01/08/2024 11:45 – Provider at bedside.  Orders given for blood work and to prepare for possible OR. Second dose of oxytocin ordered.

Vital Signs:

Lab/Diagnostic Results:

Provider Orders:

• Lactated Ringers IV at 125 mL/hr
• Oxytocin 10 units IM now
• Oxytocin 20 units IM now
• Prenatal vitamin, 1 tablet PO daily
• Acetaminophen 650 mg PO q6h PRN
• Blood work: CBC, type and crossmatch
• Uterine massage
• Vital signs q 15 minStrict intake and output
• Notify operating room of potential hysterectomy

1. Based on the client’s history and presenting symptoms, what is the most likely cause of Maria Hernandez’s postpartum hemorrhage?

a. Vaginal lacerations

b. Uterine atony

c. Retained placental fragments

d. Cervical lacerations

2. What is the priority nursing diagnosis for Maria Hernandez based on her current condition?

a. Risk for infection related to invasive procedures

b. Ineffective breastfeeding related to fatigue

c. Deficient fluid volume related to excessive blood loss

d. Acute pain related to uterine contractions

3. Which of the following interventions should the nurse anticipate implementing immediately for Maria Hernandez?

a. Administering pain medication as ordered

b. Encouraging the client to breastfeed

c. Continuing to monitor vital signs every 15 minutes

d. Preparing for a blood transfusion per provider order

4. After receiving the handoff report on Maria, you enter the room to perform your assessment.  What is your priority nursing action?

a. Administer pain medication.

b. Assess the amount of blood loss.

c. Check the client’s temperature.

d. Ask the family to leave the room.

5. You are preparing to administer the second dose of oxytocin 20 units IM.  What is the essential nursing intervention prior to administering this medication?

a. Verify the client’s blood pressure is within normal limits.

b. Assess the client’s pain level and administer analgesia if needed.

c. Palpate the fundus to assess uterine tone and position.

d. Obtain consent from the client for oxytocin administration.

6. A few days later, the nurse is providing discharge instructions to Maria Hernandez following successful treatment of her postpartum hemorrhage. What is the most important instruction for the client to understand before discharge?

a. The importance of taking iron supplements as prescribed to prevent anemia

b. How to perform pelvic floor exercises to strengthen pelvic muscles

c.  The signs and symptoms of postpartum hemorrhage and when to seek immediate medical attention

d. Proper breastfeeding techniques to ensure adequate milk supply

Mastitis Case Study^[2]

Use the following information to answer questions 1-6.

Handoff Report:

1630: This is Sofia Hernandez, a 28-year-old female (G1P1) who is 3 weeks postpartum and breastfeeding, presenting with mastitis of the left breast. She is a full code and has no known allergies.  She weighs 70 kg and has a BMI of 25.  She has been experiencing increasing pain, redness, and swelling in her left breast for the past 24 hours, accompanied by fever and chills.  She is determined to continue breastfeeding exclusively for the first six months.  Upon examination, her left breast is visibly engorged, erythematous, and tender to palpation.  She has a palpable, tender mass in the upper outer quadrant of her left breast.  Her admission vitals were: temperature 101.5°F (38.6°C), heart rate 110 bpm, respiratory rate 18 breaths/min, and blood pressure 100/60 mmHg. However, her temperature did decrease to 100.2°F.  She initially rated her pain as 8/10 on a numerical pain scale, but is now a 6/10. Please continue to monitor her vital signs, pain level, and the appearance of her left breast.  Provide support and education regarding effective breastfeeding techniques and the importance of antibiotic adherence.

Progress Notes:

•  0800 – Client admitted to postpartum floor.  Vitals signs taken and documented. Provider notified; orders received and implemented.  Client education provided regarding mastitis, treatment plan, and breastfeeding techniques.  Encouraged to maintain frequent breastfeeding or pumping.  Pain medication administered.  (J. Smith, RN)
• 1200 – Client reports continued pain and swelling in left breast, but fever has decreased to 100.2°F.  She is pumping every 2 hours.  Encouraged to continue current management.  (J. Smith, RN)
• 01/09/2024 1600 – Client reports slight improvement in pain and redness.  (J. Smith, RN)

Lab/Diagnostic Results

Provider Orders:

• Complete Blood Count (CBC)
• Blood Cultures x2, different sites
• Vancomycin 1000 mg IV every 12 hours
• Acetaminophen 650 mg PO every 6 hours PRN for pain or fever
• Encourage frequent breastfeeding or pumping of the affected breast

1. As you enter Ms. Hernandez’s room for your initial assessment, she is crying and states, “I feel awful! I just want to go home. I can’t do this anymore.”  What is the nurse’s best initial response?

a. “I understand you’re feeling overwhelmed. Tell me more about what’s making you feel this way.”

b. “You’ll feel better once you get some rest. We’ll check on you in an hour.”

c. “It’s important to stay positive. Breastfeeding is a wonderful experience for you and your baby.”

d. “I’ll contact the doctor to see if you can be discharged.”

2. Based on Ms. Hernandez’s presentation and history, what is the priority nursing diagnosis?

a. Acute pain related to breast inflammation and engorgement

b. Ineffective breastfeeding related to breast pain and engorgement

c. Hyperthermia related to infectious process

d. Risk for deficient fluid volume related to fever

3. Which of the following interventions is the most important to include in Ms. Hernandez’s plan of care?

a. Apply ice packs to the affected breast for 20 minutes every 2 hours

b. Administer ibuprofen 800 mg PO every 8 hours as needed for pain

c. Educate the client on the signs and symptoms of worsening infection

d. Encourage the client to wear a supportive bra at all times

4. You are reviewing Sofia’s laboratory results. Which of the following findings would be most indicative of an infection requiring further intervention?

a. Elevated red blood cell count

b. Increased platelet count

c. Positive blood cultures

d. Slightly elevated white blood cell count

5. Sofia’s CBC results are now available and indicate an elevated white blood cell count.  Based on Sofia’s diagnosis and assessment findings, what is the nurse’s most appropriate analysis of this result?

a. The elevated WBC count is unexpected and suggests a medication allergy.

b. The elevated WBC count indicates a possible complication of breastfeeding.

c. The elevated WBC count is consistent with the body’s response to an infection like mastitis.

d. The elevated WBC count requires no further action as it will self-resolve.

6.     After 24 hours of treatment, which finding would best indicate that Ms. Hernandez is responding favorably to the interventions?

a. Ms. Hernandez reports that her breast pain is now a 2/10 on the pain scale.

b. Ms. Hernandez’s infant is latching effectively and breastfeeding well.

c. Ms. Hernandez’s temperature is 98.8°F.

d. Ms. Hernandez expresses a desire to continue breastfeeding.