406 5 Flashcards
it is normal for _____ to occur for 12 to 24 hours post-delivery due to high oxytocin levels
contractions
post-delivery: pulse
may decrease to 50 (normal puerperal
bradycardia)
24 to 48 hours postpartum, cardiac output remains
elevated
post-delivery: ____ (especially at night) helps restore normal plasma volume.
sweating
post-delivery: WBC count is
elevated (so you can’t really use that to determine infection since it’s a normal finding)
post-delivery: changes in the blood increase the risk for
thrombus
post-delivery: GU
Diuresis occurs; woman excretes up to 3000 mL/ day of urine.
post-delivery: ____ distention and incomplete emptying are common.
Bladder
post-delivery: No bowel movements are expected for
2 to 3 days
remember the first step in teaching is
assess the current knowledge level and readiness to learn
post-delivery: RR
should be normal range
On the first postpartum day (first day following birth), the top of the fundus is located approximately
1 cm below the umbilicus
The fundus should be midline and ___ immediately after delivery
firm
blood-tinged discharge, including shreds of tissue and decidua
Lochia rubra
lochia ___ lasts 2 to 3 days postpartum
Lochia rubra
pale pinkish to brownish discharge lasting 1 week postpartum
Lochia serosa
discharge with leukocytes and degenerated cells
Lochia alba
lochia alba lasts up to _ weeks postpartum
4
after the first post partum day, the most common cause of uterine atony is
retained placental parts
The nurse must check for the presence of retained placental parts in the
lochia
placental site does not heal; lochia persists, with brisk periods of lochia rubra
Subinvolution
Women can tolerate __ __ in postpartum because the plasma volume has increased
blood loss
If not breastfeeding, teach woman nonpharmacologic measures of milk suppression:
supportive bra or binder, ice packs, and avoiding breast stimulation.
Clients should void within _ hours of delivery
4 hours
__ exercises can improve urine retention
kegel
diet during breastfeeding
add 500 cal to the prepregnancy intake
the most common reason for decreased milk production is
stress
tests for antibodies against RBCs
Coombs test
RhoGAM is given to Rh-negative mother who has a ___ ___ test
negative Coombs test
Because Rh immune globulins suppress the immune system, the client who receives both RhoGAM and the rubella vaccine should be
tested for rubella immunity at 3 months
Postpartum: Instruct client to notify health care provider or clinic promptly of: Heavy
Heavy vaginal bleeding with clots
Postpartum: Instruct client to notify health care provider or clinic promptly of: Pain on
urination
Postpartum: Instruct client to notify health care provider or clinic promptly of: Tenderness in
in calf
abstain from __ until lochia
has ceased.
sex
newborn: drug that causes depressed respirations, hypocalcemia, and hypotonia.
Magnesium sulfate given during labor
newborn: RR
30 to 60
newborn: HR
110 to 160
newborn: HR sleeping
low as 100
newborn: HR crying
high as 180
newborn: auscultate heart at which landmark
3rd or 4th intercostal
newborn: BP
80/50 (BP is not usually measured in new borns)
newborn: weight during the 1st week
they usually lose about 10%
suction ___, then ___
mouth, then nose (Hesi hint)
Aspiration: Turn neonate on side or stomach and pat firmly on the back, holding head
10 to 15 degrees lower than feet
newborn: frog position indicates
premature
Tiny white bumps that commonly appear on a baby’s face.
milia
newborn: caput succedaneum
edema under the scalp
cord abnormalities could indicate
cardiac or kidney problems
reflex: baby extends and abducts limbs
moro
reflex: when neck is turned to side, baby assumes fencing position
tonic neck
reflex: touch the base of the toe, causes the toe to curl
plantar
difference between caput succedaneum and cephalohematoma
caput crosses suture lines and is present at birth
If newborn’s temperature falls below 97.6° F (36.4° C),
place in radiant warmer and apply skin temperature
probe
to keep infant warm its acceptable to put skin to skin or
double wrap
Hypothermia -> Use up glucose -> must start using the brown fat ->
causes ketoacidosis and shock
small-for-gestational-age: Perform a ___ blood glucose assessment
heelstick
large-forgestational-age: Perform a ___ blood glucose assessment
heelstick
infants of diabetic mothers: Perform a ___ blood glucose assessment
heelstick
jittery babies: Perform a ___ blood glucose assessment
heelstick
babies with high-pitched cries: Perform a ___ blood glucose assessment
heelstick
Report any blood glucose levels under __ mg/dL in
the full-term infant
40
Report any blood glucose levels under __ mg/dL in the preterm infant
30
newborn: Normal serum glucose is
40 to 80
Large for gestational weight means the weight is above what percentile
90th
heelstick: use only the ___ surface of the heel
lateral
heelstick: after you puncture
wipe away the first drop of blood
which site do you administer the vit K
vastus lateralis
escalate if a newborn has not had a BM within
24 h
starting on day 6, the baby should use how many diapers a day
at least 6 to 8
There may be brick-red “dust” in the first
voiding
to find the urine output: weigh the wet diaper, for every
gram added, that’s 1 mL urine
Screen for phenylketonuria (PKU) after
24 hours
of breast milk or formula ingestion
Do not feed a new born is the RR is
over 60
Most ___-fed newborns eat every 3 to 4 hours
bottle
___fed infants eat every 2 to 3 hours
breast
After the initial weight loss period, the infant should
gain approximately
1 oz (30 g) per day
An infant needs about __ calories/lb for the first 6 months.
50
needs medical attention: stools ___, ___
green, liquid
needs medical attention: refusal of __ feedings in a row
2
rectal temp: insert for __ minutes
5
