Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — Postpartum ComplicationsExam Answer Templates

Marks

1

Topic

Postpartum Hemorrhage

Difficulty

easy

Template Id

T1

Examiner Tip

Examiners award this mark for precision — they want at least one correct blood loss value. Including both values (500 mL and 1,000 mL) shows thorough knowledge and protects you if one value is contested.

Model Answer

Postpartum hemorrhage (PPH) is blood loss exceeding 500 mL following a vaginal birth or exceeding 1,000 mL following a cesarean section, or any blood loss that causes hemodynamic instability in the mother.

Question Type

very_short_answer

Answer Structure

• State the definition with both blood loss thresholds in one complete sentence [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing only '>500 mL' without specifying the route of delivery — too vague for full credit
• Defining PPH as 'excessive bleeding after birth' without quantifying the amount
• Omitting all numerical thresholds

Key Phrases To Include

• >500 mL after vaginal birth
• >1,000 mL after cesarean
• hemodynamic instability

Marks

1

Topic

Postpartum Hemorrhage — Nursing Interventions

Difficulty

easy

Template Id

T2

Examiner Tip

The word 'FIRST' in NLE questions signals a priority question. Fundal massage is a nurse-initiated, independent action requiring no physician order — that is why it comes first. Stating this logic earns full marks and demonstrates clinical reasoning.

Model Answer

The first nursing action is to perform fundal massage (uterine massage) to stimulate uterine contraction and reduce blood loss from atony.

Question Type

very_short_answer

Answer Structure

• Name the specific action (fundal massage) and briefly state its rationale [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing 'administer oxytocin' as the first action — medication comes AFTER massage
• Writing 'call the physician' — nurse-initiated massage precedes physician notification
• Writing 'massage the abdomen' instead of specifying 'fundal massage'

Key Phrases To Include

• fundal massage
• uterine massage
• uterine atony
• first action

Marks

2

Topic

Uterotonic Pharmacology

Difficulty

medium

Template Id

T3

Examiner Tip

In pharmacology questions at the 2-mark level, think 'WHAT + WHY.' The first mark is for naming the contraindication; the second is for the mechanism or nursing implication. Never leave the 'why' out.

Model Answer

Methylergonovine (0.2 mg IM) is contraindicated in clients with hypertension or preeclampsia. This is significant in postpartum care because methylergonovine causes vasoconstriction, which further elevates blood pressure and can precipitate hypertensive crisis, stroke, or eclampsia in an already hypertensive postpartum client. The nurse must assess blood pressure before each dose and withhold the drug if hypertension is present, reporting to the physician and substituting another uterotonic as ordered.

Question Type

short_answer

Answer Structure

• Line 1: State the contraindication clearly (hypertension/preeclampsia) [1 mark]
• Line 2: Explain the mechanism/rationale and nursing implication [1 mark]

Scoring Breakdown

Common Mark Deductions

• Naming the contraindication but failing to explain the physiological reason — loses the second mark
• Writing 'asthma' as the contraindication — that is carboprost, not methylergonovine
• Omitting the nursing action (assess BP, withhold) in a 2-mark question

Key Phrases To Include

• hypertension
• preeclampsia
• vasoconstriction
• blood pressure
• assess BP before each dose
• withhold

Marks

2

Topic

Postpartum Hemorrhage — Assessment

Difficulty

medium

Template Id

T4

Examiner Tip

Fundal deviation is a classic NLE scenario. Examiners are testing whether you know that a deviated fundus ≠ atony — it means bladder is full. The corrective action (empty the bladder) must come before any uterotonic drug.

Model Answer

A fundus deviated to the right (off midline) indicates a full/distended urinary bladder, which is pushing the uterus to the side and preventing it from contracting properly. The appropriate nursing intervention is to assist the client to void spontaneously, or if she is unable to void, to perform urinary catheterization as ordered to empty the bladder. Once the bladder is emptied, the fundus should return to midline and become firm.

Question Type

short_answer

Answer Structure

• Line 1: Identify the cause — full bladder displacing the uterus [1 mark]
• Line 2: State the intervention — encourage voiding or catheterize as ordered [1 mark]

Scoring Breakdown

Common Mark Deductions

• Interpreting fundal deviation as uterine atony and jumping to fundal massage — incorrect interpretation
• Suggesting oxytocin administration without first addressing the bladder
• Not explaining why the bladder causes deviation (prevents uterine contraction)

Key Phrases To Include

• full bladder
• distended bladder
• deviated to the right
• prevents contraction
• encourage voiding
• catheterize

Marks

3

Topic

Postpartum Mood Disorders

Difficulty

medium

Template Id

T5

Examiner Tip

This is one of the most tested 3-mark structures in NLE maternal nursing. Organize as a numbered list with one condition per point. The examiner scans for three distinct clinical pictures — make each one clearly different from the others.

Model Answer

1. Postpartum Blues: Affects up to 80% of mothers; presents with mild mood swings, tearfulness, and irritability beginning within days of birth; resolves spontaneously within 2 weeks. The mother remains in touch with reality and is able to care for her infant. Management is reassurance and support only. 2. Postpartum Depression: A true major depressive episode occurring within the first year postpartum; characterized by persistent sadness, hopelessness, guilt, fatigue, poor concentration, and possible thoughts of self-harm or infant harm. It does NOT resolve without treatment; management requires psychotherapy and antidepressants (e.g., SSRIs such as sertraline). Screening with the Edinburgh Postnatal Depression Scale is recommended. 3. Postpartum Psychosis: A psychiatric emergency occurring within 1–2 weeks postpartum; hallmark features include delusions, hallucinations (including command hallucinations to harm the infant), and a break from reality — often linked to bipolar disorder. The nurse must NEVER leave the mother alone with the baby. Requires immediate psychiatric hospitalization, antipsychotics, and mood stabilizers.

Question Type

short_answer

Answer Structure

• Point 1: Describe postpartum blues — onset, severity, resolution, management [1 mark]
• Point 2: Describe postpartum depression — symptoms, persistence, treatment needed [1 mark]
• Point 3: Describe postpartum psychosis — emergency features, safety priority, management [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing the timing: saying psychosis occurs 'months' postpartum — it occurs within 1-2 weeks
• Stating blues requires antidepressants — it is self-limiting and needs only support
• Omitting the safety priority (never leave alone with baby) for psychosis — a critical nursing action
• Failing to distinguish that depression requires active treatment while blues resolves spontaneously

Key Phrases To Include

• mood swings
• resolves within 2 weeks
• postpartum blues self-limiting
• major depressive episode
• SSRIs / sertraline
• Edinburgh Postnatal Depression Scale
• psychiatric emergency
• delusions and hallucinations
• never leave mother alone with baby
• psychiatric hospitalization

Marks

3

Topic

Postpartum Hemorrhage — Causes

Difficulty

easy

Template Id

T6

Examiner Tip

Numbered lists are ideal here. Examiners check for two things: correct naming AND brief explanation. Noting that 'Tone is the most common' shows deeper understanding and may earn bonus credit. Include the clinical clue for Trauma (firm fundus + bright red = laceration) to stand out.

Model Answer

The four causes of PPH are remembered as the '4 Ts': 1. Tone — Uterine atony: the most common cause; the uterus fails to contract after delivery, resulting in a boggy, soft uterus and uncontrolled bleeding from the placental site. 2. Trauma — Lacerations of the cervix, vagina, or perineum, or formation of a hematoma; suspected when bleeding is bright red and steady despite a firm fundus. 3. Tissue — Retained placental fragments that prevent the uterus from fully contracting and closing off bleeding vessels. 4. Thrombin — Coagulopathies such as disseminated intravascular coagulation (DIC) that impair normal clotting and lead to uncontrolled hemorrhage.

Question Type

short_answer

Answer Structure

• Point 1: Tone — uterine atony, most common cause, boggy uterus [1 mark]
• Point 2: Trauma — lacerations/hematoma, bright red bleeding with firm fundus [0.5 mark]
• Point 3: Tissue — retained placental fragments [0.5 mark]
• Point 4: Thrombin — coagulopathies/DIC [1 mark total for T3+T4]

Scoring Breakdown

Common Mark Deductions

• Listing only the T-words without explaining what each means — loses explanation marks
• Omitting that Tone/atony is the most common cause — a key clinical priority point
• Confusing Trauma with Tissue — lacerations vs. retained placenta are distinct causes

Key Phrases To Include

• uterine atony
• most common cause
• boggy uterus
• lacerations
• bright red bleeding with firm fundus
• retained placental fragments
• coagulopathy
• DIC

Marks

3

Topic

Puerperal Infection

Difficulty

medium

Template Id

T7

Examiner Tip

The definition of puerperal infection is a frequently tested 'fill-in' fact in the NLE. Memorize the exact temperature (38°C) and the time frame (any 2 of 10 days, excluding day 1). This precision alone can earn you a full mark.

Model Answer

Puerperal (postpartum) infection is any infection of the genital tract following birth, classically defined as a temperature of 38°C (100.4°F) or higher on any two of the first ten postpartum days, excluding the first 24 hours. The most common form is endometritis — infection of the uterine lining. Three predisposing factors: 1. Cesarean birth (the single greatest risk factor) 2. Prolonged rupture of membranes (PROM) 3. Multiple vaginal examinations during labor

Question Type

short_answer

Answer Structure

• Definition with temperature threshold and time frame [1 mark]
• Identify endometritis as the most common form [0.5 mark]
• List three valid predisposing factors [1.5 marks — 0.5 each]

Scoring Breakdown

Common Mark Deductions

• Omitting 'excluding the first 24 hours' from the definition — this is a classic NLE trap
• Naming 'uterine infection' instead of the specific term 'endometritis'
• Listing fewer than three risk factors when three are explicitly requested

Key Phrases To Include

• 38°C (100.4°F)
• any 2 of the first 10 postpartum days
• excluding the first 24 hours
• endometritis
• cesarean birth
• prolonged rupture of membranes

Marks

3

Topic

Mastitis

Difficulty

medium

Template Id

T8

Examiner Tip

The single most important point examiners look for in mastitis questions is 'CONTINUE breastfeeding.' If you write 'stop breastfeeding,' you not only lose marks but demonstrate a dangerous misunderstanding. Pair this with the antibiotic (dicloxacillin) for full credit.

Model Answer

The condition is mastitis — an infection of the breast tissue caused most commonly by Staphylococcus aureus entering through a cracked or fissured nipple, exacerbated by milk stasis. Nursing Management: 1. Continue breastfeeding or pumping from the affected breast — emptying the breast is therapeutic and prevents abscess formation; breast milk from the affected side remains safe for the infant. 2. Administer prescribed antibiotics effective against S. aureus (e.g., dicloxacillin or cephalexin) for the full course; use clindamycin/vancomycin for MRSA. 3. Apply warm compresses before feeding (promotes milk flow) and cold compresses after feeding (reduces inflammation and discomfort). 4. Administer analgesics/antipyretics as prescribed and encourage rest and adequate hydration. 5. Teach preventive measures: proper latch and infant positioning, frequent breast emptying, alternating feeding sides, avoiding tight-fitting bras, and nipple care to prevent cracking.

Question Type

short_answer

Answer Structure

• Identify the condition: mastitis, causative organism (S. aureus), entry via cracked nipple [1 mark]
• State 2-3 key management steps with rationale [2 marks]

Scoring Breakdown

Common Mark Deductions

• Advising the mother to STOP breastfeeding — this is incorrect and a critical clinical error
• Omitting the causative organism (S. aureus) when identifying the condition
• Listing only comfort measures without mentioning antibiotic therapy

Key Phrases To Include

• mastitis
• Staphylococcus aureus
• cracked nipple
• continue breastfeeding
• milk stasis
• dicloxacillin or cephalexin
• warm compresses before feeding
• breast emptying is therapeutic

Marks

2

Topic

Thrombophlebitis / DVT

Difficulty

medium

Template Id

T9

Examiner Tip

DVT questions almost always test the 'do not massage' rule. Examiners specifically want to see that you understand WHY — because of embolism risk. The word 'justify' in the question signals that the rationale is worth a mark, not just the instruction itself.

Model Answer

The most important nursing instruction is: DO NOT massage the affected leg. This is because DVT involves a blood clot (thrombus) in the deep vein of the leg, and massaging the area can dislodge the clot, causing it to travel to the lungs as a pulmonary embolism — a life-threatening emergency characterized by sudden dyspnea, pleuritic chest pain, and tachycardia. Instead, the nurse should keep the leg elevated, apply warm moist compresses for comfort, maintain bed rest, administer anticoagulants as ordered (heparin or enoxaparin), and monitor for signs of pulmonary embolism.

Question Type

short_answer

Answer Structure

• Line 1: State the instruction — Do NOT massage the leg [1 mark]
• Line 2: Justify — risk of embolism if clot dislodged [1 mark]

Scoring Breakdown

Common Mark Deductions

• Recommending massage as part of DVT care — a dangerous clinical error that will lose all marks
• Stating the instruction correctly but not providing the justification (pulmonary embolism risk)
• Confusing the anticoagulant: writing 'warfarin' as first-line in the acute phase (heparin/enoxaparin is used first)

Key Phrases To Include

• do not massage
• thrombus
• dislodge the clot
• pulmonary embolism
• elevate the leg
• anticoagulants
• heparin or enoxaparin

Marks

2

Topic

Anticoagulant Therapy — DVT

Difficulty

hard

Template Id

T10

Examiner Tip

This is a high-yield pharmacology pairing in the NLE. Memorize it as a table in your mind: Heparin = safe in pregnancy = protamine antidote = aPTT monitoring. Warfarin = teratogenic = Vitamin K antidote = INR monitoring. Getting the antidotes crossed is a common error.

Model Answer

Heparin (including low-molecular-weight heparin/enoxaparin): Safe in both pregnancy and lactation because it does NOT cross the placenta and does not enter breast milk in significant amounts. It is the first-line anticoagulant for DVT in pregnant and breastfeeding women. The antidote is protamine sulfate. Monitored with aPTT (for unfractionated heparin). Warfarin: Teratogenic — crosses the placenta and causes fetal hemorrhage and malformations (warfarin embryopathy), so it is AVOIDED during pregnancy. It is considered acceptable postpartum during lactation in small doses. The antidote is Vitamin K. Monitored with INR (target 2–3 for DVT).

Question Type

short_answer

Answer Structure

• Describe heparin: safety in pregnancy/lactation, antidote (protamine) [1 mark]
• Describe warfarin: teratogenic in pregnancy, acceptable postpartum, antidote (Vitamin K) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating warfarin is safe in pregnancy — it is teratogenic and a critical NLE error
• Mixing up antidotes: giving Vitamin K for heparin or protamine for warfarin
• Omitting the monitoring parameter (aPTT for heparin, INR for warfarin)

Key Phrases To Include

• does not cross the placenta
• safe in pregnancy and lactation
• protamine sulfate
• aPTT
• warfarin is teratogenic
• Vitamin K
• INR

Marks

2

Topic

Pulmonary Embolism — DVT Complication

Difficulty

medium

Template Id

T11

Examiner Tip

NLE frequently presents PE as a sudden deterioration scenario. The triad to memorize is: sudden dyspnea + pleuritic chest pain + tachycardia. The priority action is airway/breathing (oxygen) followed immediately by physician notification. This follows ABC (Airway-Breathing-Circulation) prioritization.

Model Answer

Classic signs and symptoms of pulmonary embolism: 1. Sudden dyspnea (difficulty breathing) 2. Pleuritic chest pain (sharp pain that worsens with breathing) 3. Tachycardia and tachypnea (Additional findings: apprehension, hemoptysis, and decreased oxygen saturation) Priority nursing action: Position the client upright to ease breathing, administer high-flow supplemental oxygen immediately, and notify the physician/activate the emergency response team — pulmonary embolism is a life-threatening emergency requiring immediate medical intervention.

Question Type

short_answer

Answer Structure

• List three signs/symptoms of PE [1 mark]
• Identify and briefly explain the priority nursing action [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing DVT symptoms (leg swelling, redness) instead of PE symptoms
• Stating 'call the doctor' without mentioning oxygen administration first
• Omitting the urgency — not labeling PE as a life-threatening emergency

Key Phrases To Include

• sudden dyspnea
• pleuritic chest pain
• tachycardia
• tachypnea
• hemoptysis
• supplemental oxygen
• life-threatening emergency
• notify physician immediately

Marks

3

Topic

Uterotonic Pharmacology — Carboprost

Difficulty

hard

Template Id

T12

Examiner Tip

The NLE loves to test carboprost by giving an asthmatic PPH patient and asking which drug is contraindicated. Memorize: 'Carboprost = Asthma contraindicated.' The mechanism (bronchospasm) is worth an extra mark when included. Confirm the dose: 250 mcg (micrograms), not milligrams.

Model Answer

Carboprost (15-methyl prostaglandin F2-alpha) is a uterotonic drug used in the management of postpartum hemorrhage when oxytocin and methylergonovine have failed or are contraindicated. Dose and Route: 250 mcg administered intramuscularly (IM), may be repeated every 15–90 minutes as needed, up to a maximum of 8 doses. Contraindication: Asthma (active or history) — carboprost causes bronchospasm due to its prostaglandin action on bronchial smooth muscle, which can trigger severe bronchoconstriction in asthmatic clients. Two significant side effects: 1. Diarrhea — the most common side effect, due to prostaglandin stimulation of gastrointestinal smooth muscle. 2. Fever/flushing — transient hyperthermia and flushing are frequently reported; the nurse should not mistake drug-induced fever for signs of infection. Nursing consideration: Auscultate lung sounds before administration, confirm absence of asthma history, and monitor for respiratory distress after the dose.

Question Type

short_answer

Answer Structure

• State dose and route: 250 mcg IM [1 mark]
• State contraindication: asthma, with rationale (bronchospasm) [1 mark]
• List two side effects: diarrhea, fever/flushing [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing carboprost's contraindication (asthma) with methylergonovine's (hypertension)
• Omitting the dose or writing it incorrectly (e.g., 250 mg instead of 250 mcg — a 1,000-fold error)
• Not mentioning the nursing action of checking for asthma history before administration

Key Phrases To Include

• 250 mcg IM
• prostaglandin
• asthma
• bronchospasm
• diarrhea
• fever
• flushing
• every 15–90 minutes

Marks

5

Topic

Postpartum Hemorrhage — Comprehensive Nursing Care

Difficulty

hard

Template Id

T13

Examiner Tip

For 5-mark long answers, examiners are looking for a complete clinical picture. Use the ADPIE framework as your outline: Assessment → Diagnosis → Planning → Intervention → Evaluation. Write in bullet/numbered format rather than paragraphs for clarity and to ensure the examiner can award marks efficiently. Every intervention MUST have a rationale — that is where half the intervention marks come from.

Model Answer

I. ASSESSMENT Subjective: Client reports feeling weak, dizzy, and 'soaking through pads quickly.' Objective: Boggy, soft uterus palpated above the umbilicus; lochia rubra — soaking more than 1 pad in 30 minutes; blood pressure 90/60 mmHg (hypotension); pulse 110 bpm (tachycardia); respiratory rate 22 bpm; pale, diaphoretic skin; cold extremities. Blood loss estimated at >500 mL post-vaginal delivery. II. NURSING DIAGNOSIS (Priority — Maslow: Physiological/Safety) Deficient Fluid Volume related to excessive blood loss secondary to uterine atony, as evidenced by boggy uterus, hypotension (90/60 mmHg), tachycardia (110 bpm), and estimated blood loss >500 mL. III. PLANNING / GOALS Short-term: Client will demonstrate improved uterine tone (firm fundus) within 15 minutes of nursing interventions. Long-term: Client will maintain stable vital signs (BP >90/60 mmHg, HR <100 bpm) and lochia within normal limits (not saturating >1 pad/hour) within 1 hour of interventions. IV. NURSING INTERVENTIONS 1. Perform fundal massage immediately. Rationale: Stimulates uterine smooth muscle contraction, closes off open blood vessels at the placental implantation site, and is the first nurse-independent action for uterine atony — no physician order required. 2. Assess and empty the urinary bladder (encourage voiding; catheterize if unable to void). Rationale: A distended bladder displaces the uterus laterally (deviated fundus) and mechanically prevents adequate uterine contraction. Emptying the bladder allows the uterus to descend to midline and contract effectively. 3. Administer uterotonic medications as ordered (oxytocin 10–40 units in 1 L IV infusion as first-line; methylergonovine 0.2 mg IM if BP is normal; carboprost 250 mcg IM if not asthmatic). Rationale: Uterotonics pharmacologically stimulate myometrial contraction when massage alone is insufficient. Selecting the appropriate agent requires checking for contraindications (hypertension for methylergonovine; asthma for carboprost) to ensure client safety under RA 9173 standards of safe medication administration. 4. Establish and maintain large-bore IV access (2 lines if possible); administer IV fluids and blood products as ordered; monitor intake and output; send blood for CBC, type and crossmatch, and coagulation studies. Rationale: Restores intravascular volume to prevent hypovolemic shock; blood products correct the oxygen-carrying capacity deficit. Coagulation studies rule out DIC as a concurrent cause. 5. Position the client supine or slightly Trendelenburg (legs elevated 15–30°); apply warm blankets; administer supplemental oxygen at 8–10 L/min via face mask. Rationale: Supine/Trendelenburg promotes venous return to the heart and vital organs. Oxygen supplementation compensates for reduced RBC mass and prevents tissue hypoxia. V. EVALUATION The following indicate effective management and goal achievement: - Fundus is firm and at midline, at or below the umbilicus - Lochia rubra is within normal limits (not saturating >1 pad/hour; no large clots) - Vital signs stabilize: BP ≥100/60 mmHg, HR ≤100 bpm, RR 16–20 bpm - Urine output is ≥30 mL/hour (indicates adequate renal perfusion) - Client reports decreased dizziness; skin color and temperature normalizing - No signs of shock (restlessness, confusion, mottling)

Question Type

long_answer

Answer Structure

• Assessment: Subjective and objective data with specific clinical values [1 mark]
• Nursing Diagnosis: Priority NANDA diagnosis with related-to and as-evidenced-by using data from assessment [1 mark]
• Three Priority Interventions: Each with a clear rationale explaining WHY [2 marks — 0.5 marks per intervention + rationale]
• Evaluation: At least 3 measurable outcome criteria indicating goal achievement [1 mark]

Scoring Breakdown

Common Mark Deductions

• Starting with medications as the first intervention instead of fundal massage — incorrect prioritization
• Writing a nursing diagnosis without the 'related to' and 'as evidenced by' components — incomplete NANDA format
• Providing interventions without rationale — loses all rationale marks
• Writing evaluation criteria that are not measurable (e.g., 'client will feel better') — too vague
• Failing to address bladder assessment as the second priority intervention
• Omitting contraindications for uterotonic drugs — a safety-critical omission

Key Phrases To Include

• Deficient Fluid Volume
• uterine atony
• boggy uterus
• fundal massage — first action
• empty the bladder
• oxytocin first-line
• methylergonovine — check BP
• carboprost — check for asthma
• large-bore IV
• urine output ≥30 mL/hr
• firm fundus
• Maslow's hierarchy
• NANDA

Marks

5

Topic

Normal Involution and Complication Detection

Difficulty

medium

Template Id

T14

Examiner Tip

Examiners award marks for specificity. 'One fingerbreadth per day' earns a mark — 'the uterus goes down slowly' does not. For lochia, list all three stages with exact timing. Structure deviation responses as: deviation → what it means → what you do. This formula makes your answer examiner-friendly.

Model Answer

UTERINE INVOLUTION: NORMAL CHANGES AND CLINICAL DEVIATIONS I. Normal Fundal Changes: Immediately after delivery, the fundus is firm and palpable at the level of the umbilicus or just below it. Beginning on the first postpartum day, the fundus descends at a rate of approximately one fingerbreadth (1 cm) per day. By day 10, the fundus is no longer palpable above the symphysis pubis. The uterus reaches its pre-pregnant size by approximately 6 weeks postpartum. Normal fundus characteristics: firm, midline, and progressively descending 1 fingerbreadth/day. II. Normal Lochia Changes: Lochia progresses through three expected stages: 1. Lochia Rubra — dark red, fleshy odor; days 1–3; contains blood, decidua, and epithelial cells. 2. Lochia Serosa — pinkish-brown, serous; days 4–10; contains old blood, serous fluid, and leukocytes. 3. Lochia Alba — yellowish-white; from approximately day 11 up to 6 weeks; contains leukocytes, mucus, and bacteria. Normal lochia should NOT be foul-smelling. Amount decreases progressively with each stage. III. Deviations from Normal and Associated Complications: 1. Boggy/soft uterus at any assessment: Indicates uterine atony — risk of postpartum hemorrhage. Action: Fundal massage, assess bladder, notify physician. 2. Fundus deviated from midline (usually right): Indicates full bladder displacing the uterus. Action: Have client void or catheterize. 3. Fundus at or above the umbilicus after day 1, OR fundus that does not descend as expected (subinvolution): May indicate retained placental fragments or endometritis. Action: Assess lochia, check temperature, report to physician. 4. Return of bright red lochia after progression to serosa or alba: Indicates abnormal bleeding — possible subinvolution, exertion-related bleeding, or retained placenta. Action: Count/weigh pads, assess fundus, restrict activity, notify physician. 5. Foul-smelling lochia with fever and uterine tenderness: Indicates endometritis (puerperal infection). Action: Culture lochia, administer prescribed antibiotics (clindamycin + gentamicin), position in semi-Fowler for drainage, monitor temperature. 6. Large clots in lochia: Abnormal; may indicate poor uterine contraction or retained tissue. Action: Assess fundus firmness, quantify blood loss, notify physician. IV. Teaching the Postpartum Client: Teach the mother to report immediately: heavy bleeding (saturating a pad per hour), foul-smelling lochia, return of bright-red blood after progressing to serosa/alba, fever, or breast/leg symptoms. This health teaching fulfills the nurse's responsibility under RA 9173, Section 28 — the scope of nursing practice includes health education and discharge planning.

Question Type

long_answer

Answer Structure

• Fundal changes: normal descent (1 fingerbreadth/day), characteristics [1 mark]
• Lochia changes: all three stages with colors, timing, and characteristics [1 mark]
• At least three deviations with associated complications and nursing actions [2 marks]
• Client health teaching with at least 3 warning signs to report [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing the order or timing of lochia stages (e.g., placing serosa before rubra)
• Not connecting deviations to specific complications (just listing symptoms without explaining what they mean)
• Omitting the rate of fundal descent (1 fingerbreadth/day) — a specific factual mark
• Writing health teaching that is too general (e.g., 'report any problems') without specifying warning signs

Key Phrases To Include

• one fingerbreadth per day
• non-palpable by day 10
• lochia rubra — days 1–3
• lochia serosa — days 4–10
• lochia alba — day 11 to 6 weeks
• foul-smelling lochia
• subinvolution
• deviated fundus — full bladder
• return of bright-red bleeding
• saturating a pad per hour
• semi-Fowler for drainage

Marks

5

Topic

Puerperal Infection — Endometritis

Difficulty

hard

Template Id

T15

Examiner Tip

Case study questions are where clinical reasoning earns marks, not just memorization. Examiners award marks for logical sequencing: CULTURE FIRST, then antibiotics. They look for the specific position (semi-Fowler — not just 'comfortable position') and for the sepsis monitoring as evidence that you think beyond the immediate problem. Always close with measurable, patient-centered outcomes.

Model Answer

I. MEDICAL/CLINICAL DIAGNOSIS The most likely diagnosis is Endometritis (postpartum uterine infection / puerperal infection). This is supported by: temperature ≥38°C occurring after the first 24 postpartum hours, foul-smelling lochia, uterine tenderness (subinvolution), chills, and malaise. Risk factors for this client include potential prolonged labor or multiple vaginal examinations. The most common causative organisms are anaerobes and gram-negative rods; broad-spectrum coverage is required. II. PRIORITY NURSING DIAGNOSIS (Maslow: Physiological Safety) Hyperthermia related to bacterial infection of the uterine endometrium (endometritis), as evidenced by temperature of 38.6°C, chills, tachycardia, and malaise. Secondary diagnosis: Risk for Sepsis related to ascending uterine infection and inadequate treatment. III. NURSING INTERVENTIONS WITH RATIONALE 1. Obtain lochia culture and blood cultures BEFORE initiating antibiotic therapy; then administer prescribed broad-spectrum IV antibiotics (commonly clindamycin + gentamicin as ordered). Rationale: Cultures identify the causative organism and ensure antibiotic selection is appropriate. Antibiotics must be given BEFORE results return but AFTER cultures are obtained to avoid altering culture results. This is consistent with evidence-based infection management protocols in Philippine tertiary hospitals. 2. Position the client in semi-Fowler's position (30–45° head elevation). Rationale: Promotes dependent drainage of lochia and purulent discharge from the uterus by gravity, preventing pooling of infected material that can lead to peritonitis or sepsis. Also facilitates breathing and comfort. 3. Monitor temperature every 4 hours; administer antipyretics (paracetamol/acetaminophen) as ordered; encourage oral fluid intake of at least 2–3 L/day or administer IV fluids as ordered. Rationale: Fever monitoring tracks the effectiveness of antibiotic therapy. Antipyretics reduce metabolic demand and discomfort. Adequate hydration replaces insensible fluid losses from fever and supports renal function and antibiotic excretion. 4. Teach and enforce perineal hygiene: front-to-back (anterior-to-posterior) perineal wiping, frequent perineal pad changes every 2–4 hours or when soiled, and thorough handwashing before and after pad changes. Rationale: Prevents ascending contamination from perianal flora into the uterine environment and reduces risk of secondary infection or worsening endometritis. This is a key infection control measure aligned with Philippine DOH guidelines. 5. Monitor for signs of sepsis: escalating fever (>39°C), increasing tachycardia (>100 bpm), hypotension, altered sensorium, and oliguria (<30 mL/hr urine output). Rationale: Untreated endometritis can progress to septicemia and septic shock — a life-threatening complication. Early recognition allows timely escalation of care. IV. EXPECTED PATIENT OUTCOMES - Temperature returns to normal (36.1°C–37.2°C) within 24–48 hours of antibiotic initiation - Lochia becomes non-foul-smelling and returns to normal progression (rubra to serosa) - Uterine tenderness resolves - Client demonstrates proper perineal hygiene technique before discharge - No signs of sepsis: vital signs stable, urine output ≥30 mL/hr, oriented and alert - Client verbalizes understanding of the importance of completing the full antibiotic course

Question Type

case_study

Answer Structure

• Identify the clinical diagnosis with supporting assessment data [1 mark]
• State the priority nursing diagnosis in NANDA format with Maslow justification [1 mark]
• Provide 3–4 interventions each with a clear, specific rationale [2 marks]
• List measurable expected outcomes (at least 3) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Starting antibiotics before obtaining cultures — incorrect sequence, loses rationale mark
• Omitting the semi-Fowler positioning or not explaining why (gravity drainage of infected lochia)
• Writing evaluation criteria that are non-measurable or unrelated to the interventions
• Failing to identify risk for sepsis as a secondary concern — shows incomplete clinical thinking
• Not mentioning perineal hygiene education — a key nursing intervention for genital tract infections

Key Phrases To Include

• endometritis
• puerperal infection
• cultures before antibiotics
• clindamycin + gentamicin
• semi-Fowler position
• lochia drainage
• perineal hygiene
• front-to-back wiping
• monitor for sepsis
• temperature normalized
• urine output ≥30 mL/hr