A nurse is teaching a class to clients who are pregnant.
Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)

Complete the sentence: The nurse should massage the uterus and prepare to administer oxytocin.

Rationale for correct answers:
Uterine atony is the most common cause of postpartum hemorrhage (PPH), indicated by a boggy uterus and heavy bleeding with clots. Uterine massage stimulates uterine contractions, promoting involution and reducing bleeding. Oxytocin is a first-line uterotonic agent that increases uterine tone by stimulating smooth muscle contraction, helping to control hemorrhage. Normal hemoglobin is 11-16 g/dL; the client’s drop to 9.4 g/dL and hematocrit decrease to 27% (normal 33%-47%) indicate blood loss requiring prompt intervention.

Rationale for incorrect Response 1 options:
Inserting an indwelling urinary catheter is unnecessary here because the client emptied her bladder without difficulty, and urinary retention is not evident. Oxygen administration by nasal cannula is not indicated since the client’s respiratory rate is normal and there is no sign of hypoxia. Immediate oxygen is reserved for hypoxic or unstable patients.

Rationale for incorrect Response 2 options:
Administering oxygen by nasal cannula is not needed without hypoxia signs. Initiating a 1000 mL sodium chloride bolus might be considered later if hypovolemia or hypotension worsens but is not the immediate priority. Inserting an indwelling urinary catheter is not indicated as the bladder is emptying normally, and unnecessary catheterization risks infection.

Take-home points:

• Postpartum hemorrhage is primarily caused by uterine atony, presenting with a boggy uterus and heavy bleeding.
• Prompt uterine massage and administration of oxytocin are critical first-line interventions to control bleeding.
• Laboratory values such as hemoglobin and hematocrit help assess blood loss severity and guide management.
• Differentiation from other causes of bleeding (e.g., retained placenta, lacerations) requires assessment but initial treatment focuses on uterine tone restoration.

Rationale for correct condition:
Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, typically in the fallopian tube. The absence of an intrauterine pregnancy on transvaginal ultrasound at an hCG level of 2000 IU/L (above the discriminatory zone of 1500-2000 IU/L) strongly suggests ectopic pregnancy. The patient’s left lower quadrant pain and vaginal bleeding are classic signs. Progesterone >4 ng/dL indicates a potentially viable pregnancy, but no intrauterine gestation confirms ectopic risk. Early diagnosis is crucial to prevent tubal rupture and hemorrhagic shock.

Rationale for correct actions:
Intramuscular methotrexate is a folic acid antagonist used to medically manage unruptured ectopic pregnancies by inhibiting trophoblastic cell division. It is preferred when the patient is hemodynamically stable, avoiding surgery. CBC monitors for anemia from bleeding; liver function tests assess methotrexate toxicity risk, as the drug is hepatotoxic. Both are essential for safe medical management.

Rationale for correct parameters:
Hypotension indicates potential internal bleeding from tubal rupture requiring immediate intervention. Referred shoulder pain occurs from diaphragmatic irritation by blood in the peritoneal cavity, signaling intra-abdominal hemorrhage. Monitoring these signs allows early detection of complications.

Rationale for incorrect conditions:
Spontaneous abortion typically shows declining hCG and intrauterine findings of miscarriage, which are absent here. Molar pregnancy presents with markedly elevated hCG (>100,000 IU/L) and characteristic ultrasound “snowstorm” appearance, not seen. Cervical insufficiency causes painless cervical dilation in the second trimester, not early pregnancy pain with bleeding.

Rationale for incorrect actions:
Dilation and curettage is indicated in incomplete abortion, not ectopic pregnancy. Cervical cerclage treats cervical insufficiency, unrelated to this presentation. Oxytocic agents induce uterine contractions in miscarriage or labor, not ectopic management.

Rationale for incorrect parameters:
Size of uterus is irrelevant here because no intrauterine pregnancy is seen. Uterine cramping is nonspecific and more relevant in miscarriage. Leakage of amniotic fluid occurs in membrane rupture, not ectopic pregnancy.

Take-home points:

• Absence of intrauterine pregnancy at hCG >1500 IU/L suggests ectopic pregnancy.
• Methotrexate is first-line medical treatment for stable ectopic pregnancies.
• Hypotension and referred shoulder pain are critical signs of rupture and hemorrhage.
• Differentiation from miscarriage, molar pregnancy, and cervical insufficiency is vital for appropriate care.