Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

RNSG 1251 UNIT 3 > ch. 21: nursing care during postpartum period > Flashcards

ch. 21: nursing care during postpartum period Flashcards

1
Q

What are normal assessment findings of the BREASTS?

A

soft ,filling, full, soften w/ breastfeeding, nipple skin intact, no soreness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are signs of potential complications when assessing BREASTS?

A

-engorgement: firmness, heat, pain
-nipple redness, pain, crackles usually associated w/ latching prblms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are normal assessment findings of the UTERUS?

A

-firm, midline
-first 24 hrs at umbilicus level
-involutes 1 FB/cm a day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are signs of potential complications when assessing the UTERUS?

A

-ATONY: soft, boggy, higher than expected
-LATERAL DEVIATION: due to distended bladder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are normal assessment findings of the BLADDER?

A

-able to void spontaneously
-no distention
-able to empty bladder completely
-no dysuria
-diuresis begins 12 hrs after birth, can void 3,000 ml/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are signs of potential complications when assessing the BLADDER?

A

-overdistended bladder
-excessive lochia
-infection: dysuria, frequency, urgency, burning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are normal assessment findings of the BOWELS?

A

-abdomen soft
-active bowel sounds q4
-BM by day 2 or 3 after birth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are signs of potential complications when assessing the BOWELS?

A

-NO BM by day 3 or 4
-constipation
-diarrhea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When is LOCHIA RUBRA present and what color is it?

A

-days 1-3
-dark red color

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

When is LOCHIA SEROSA present and what color is it?

A

-days 4 to 10
-brownish, red, or pink color

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

When is LOCHIA ALBA present and what color is it?

A

-after 10 days
-yellowish white color

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are normal assessment findings of LOCHIA?

A

-amount: scant to moderate
-few clots
fleshy odor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are signs of potential complications when assessing LOCHIA?

A

-uterine atony, vaginal or cervical lacerations: a large amount of lochia, large clots (bigger than fists)
-infection: foul odor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are normal assessment findings of an EPISIOTOMY?

A

-edges approximated
-pain minimal to moderate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are signs of potential complications when assessing an EPISIOTOMY?

A

-infection: redness, warmth, drainage
-excessive discomfort first 1 to 2 days: hematoma
-after 3 days: infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are normal assessment findings of the LEGS/ HOMANS SIGN?

A

-DTRs 1 + to 2 +
-peripheral edema possible
-NEGATIVE Homans sign

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are signs of potential complications when assessing the LEGS/ HOMANS SIGN?

A

-preeclampsia: DTRs ≥ 3+
-positive homans sign

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are normal assessment findings of their EMOTIONAL STATE?

A

-excited, happy, interested or involved in infant care

19
Q

What are signs of potential complications when assessing their EMOTIONAL STATE?

A

-pospartum depression: lethargy, extreme fatigue, difficulty sleeping
-postpartum blues/depression: sad, tearful, disinterested in infant care

20
Q

Why is an H&H ordered for a postpartum pt?

A

to assess blood loss during birth, especially c-section

21
Q

Why is a URINALYSIS ordered for a postpartum pt?

A

for routine urinalysis or culture, especially if pt had a urinary catheter

22
Q

Why is a RUBELLA TITER ordered for a postpartum pt?

A

-to determine the status- and possible treatment
-if woman hasn’t had rubella or is serologically nonimmune (titer of 1:8 or less) they shou;d get a SUBQ INJ OF RUBELLA VACCINE before discharge

23
Q

Why is a RHOGAM (FETAL SCREEN) ordered for a postpartum pt?

A

to detect pts who may need more than one dose of RHOGAM due to sig fetal bleeding

24
Q

What is considered SCANT bleeding/lochia?

A

< 2.5 cm pad saturation

25
Q

What is considered LIGHT bleeding/lochia?

A

< 10 cm pad saturation

26
Q

What is considered MODERATE bleeding/lochia?

A

> 10 cm pad satuartion

27
Q

What is considered HEAVY bleeding/lochia?

A

one pad completely saturated within 2 hrs

28
Q

How do you weigh blood amount on pad?

A

1g= 1mL of blood

29
Q

What do you document about LOCHIA (COCA)?

A

C olor
O dor
C onsistency
A mount

30
Q

What are 3 nursing interventions to maintain uterine tone?

A

1) gently massage the fundus until firm
2) empty bladder if distended
3) IV oxytocic meds

31
Q

How does a full bladder place the pt at risk for EXCESSIVE BLEEDING?

A

a full bladder causes uterus to be displaced above umbilicus & well to one side of midline in abd & PREVENTS UTERUS FROM CONTRACTING NORMALLY

32
Q

What position do you place a pt when assessing the EPISIOTOMY?

A

SIMS POSITION

33
Q

What do you document when assessing the episiotomy (REEDA)?

A

R edness
E dema
E cchymosis
D risharge
A pproximation

34
Q

What are 3 nursing interventions for perineal lacerations/episiotomy?

A

1) cleansing and changing pads (front to back)
2) apply ice pack for pain
3) squeeze bottle or sitz bath

35
Q

How do perineal lacerations/episiotomy place pt at risk for infection?

A

increase risk for infection as result of interruption of skin integrity

36
Q

What education should you provide to the pt to decrease the risk of infection of perineal lacerations/episiotomy?

A

-wipe from front to back
-use squeeze bottle to clean wound after voiding
-change perineal pad from front to back

37
Q

What are non-pharmacologic interventions to promote comfort?

A

-heating pad
-massage
-ice pack
-distraction
-light touch
-relaxation
-aromatherapy

38
Q

What are 3 pharmacologic interventions to promote comfort?

A

-NSAIDs
-topical antiseptics or anesthetics
-PCA and epidural analgesia

39
Q

What are 3 nursing interventions to PREVENT THROMBOEMBOLISM?

A

-early ambulation
-TED hose or SCD boot
-exercise to promote circulation if bedrest

40
Q

How do you assist the postpartum pt the first time they are getting out of bed?

A

-assess their ability to stand on their own, if unable to balance herself ease her back onto bed
-important to have hospital personnel present at first time

41
Q

What is the recommended caloric intake for a NON-LACTATING POSTPARTUM PT?

A

1800- 2200 kcal/day

42
Q

What is the recommended caloric intake for a LACTATING POSTPARTUM PT?

A

1800- 2200 PLUS ANOTHER 450-500 kcal/ day

43
Q

What are 3 signs that parents are adapting well to parenthood?

A

1) taking pleasure in infant and providing care
2) responding appropriately to infant cues
3) providing comfort to infant

RNSG 1251 UNIT 3 (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions