CFRN Obstetrical Patient Management 5 — Questions and Answers
Question 1: A flight nurse receives a patient who delivered vaginally 2 hours ago and now has a boggy uterus that does not firm with fundal massage and oxytocin infusion. What is the MOST likely cause of her ongoing hemorrhage?
- Retained placental fragments
- Cervical laceration
- Uterine atony refractory to oxytocin (Correct answer)
- Consumptive coagulopathy (DIC)
Correct answer: Uterine atony refractory to oxytocin
A uterus that fails to contract despite massage and oxytocin represents refractory uterine atony, the most common cause of postpartum hemorrhage.
Question 2: A patient at 20 weeks gestation requires intubation during air transport. Compared to a non-pregnant patient, rapid sequence intubation in pregnancy requires consideration of:
- Decreased aspiration risk due to lower gastric volumes
- Faster oxygen desaturation and increased aspiration risk (Correct answer)
- Higher succinylcholine dose due to increased plasma volume
- Avoidance of cricoid pressure to prevent airway trauma
Correct answer: Faster oxygen desaturation and increased aspiration risk
Pregnancy decreases FRC and increases oxygen consumption, causing rapid desaturation; delayed gastric emptying and increased gastric acid raise aspiration risk during intubation.
Question 3: A 36-week patient is transported after an eclamptic seizure that has now resolved. She is postictal with a GCS of 12. What is the MAINTENANCE dose of magnesium sulfate for seizure prophylaxis?
- 1–2 g/hr IV infusion (Correct answer)
- 4–6 g IV bolus repeated every hour
- 500 mg IM every 4 hours
- 10 g IM loading dose only
Correct answer: 1–2 g/hr IV infusion
After a 4–6 g IV loading dose, magnesium sulfate is maintained at 1–2 g/hr IV infusion to prevent recurrent eclamptic seizures.
Question 4: During flight, a multiparous patient at 39 weeks suddenly reports an urge to push. Exam reveals crowning. Which step of emergency delivery management should be performed FIRST?
- Apply gentle steady pressure to the fetal head to control delivery (Correct answer)
- Prepare for immediate episiotomy to expedite delivery
- Administer IV morphine for pain control before delivery
- Place the patient in Trendelenburg to delay delivery
Correct answer: Apply gentle steady pressure to the fetal head to control delivery
Controlled delivery of the fetal head with gentle steady pressure prevents rapid expulsion, reduces perineal lacerations, and allows the infant's airway to clear.
Question 5: A 31-week gestation patient with preterm premature rupture of membranes (PPROM) is transported. Which finding would indicate chorioamnionitis requiring immediate delivery consideration?
- Mild uterine cramping without fever
- Maternal fever >38°C, uterine tenderness, and fetal tachycardia (Correct answer)
- Clear amniotic fluid leakage with a normal fetal heart rate
- Cervical dilation of 2 cm without contractions
Correct answer: Maternal fever >38°C, uterine tenderness, and fetal tachycardia
Chorioamnionitis is diagnosed clinically by maternal fever combined with uterine tenderness and fetal tachycardia, indicating intrauterine infection that may require delivery.
Question 6: When assessing a pregnant patient during high-altitude aeromedical transport, the flight nurse knows that altitude-related hypoxia is particularly dangerous because the fetal hemoglobin-oxygen dissociation curve:
- Shifts right, increasing fetal oxygen release to tissues
- Shifts left, allowing fetal hemoglobin to hold oxygen more tightly at lower PaO2 (Correct answer)
- Remains unchanged compared to adult hemoglobin
- Shifts right at altitude, improving placental oxygen transfer
Correct answer: Shifts left, allowing fetal hemoglobin to hold oxygen more tightly at lower PaO2
Fetal hemoglobin has a left-shifted dissociation curve, enabling it to extract oxygen from maternal blood at lower oxygen tensions, but maternal hypoxia still reduces placental oxygen availability.
Question 7: A patient is transported at 38 weeks with a history of previous cesarean section and is now in active labor. She suddenly develops acute onset of severe tearing abdominal pain, cessation of contractions, and the previously engaged fetal head is now unengaged. This presentation is MOST consistent with:
- Placental abruption with fetal distress
- Complete uterine rupture (Correct answer)
- Rapid cervical dilation causing round ligament pain
- Placenta previa with hemorrhage
Correct answer: Complete uterine rupture
Sudden severe abdominal pain, loss of previously palpable uterine contractions, and retraction of the fetal presenting part are the hallmark signs of complete uterine rupture.
CFRN Obstetrical Patient Management 5
A flight nurse receives a patient who delivered vaginally 2 hours ago and now has a boggy uterus that does not firm with fundal massage and oxytocin infusion.
What is the MOST likely cause of her ongoing hemorrhage?