EXAM #3 Flashcards
What to assess on mother in the first 24 hours after birth
-Temp: normal to drop 2 hours after birth. Normal to raise for 24 hours
-Pulse
-Respirations
-BP
-Fundus: Midline, firm at umbilicus
-Lochia
-Episiotomy
-Hemorrhoids
-Bladder
-Homan’s sign neg. DVT
-Mood
-Bonding and attachment
How long is severe pain expected postpartum & what nursing interventions should be implemented?
-2-3 days
-Prone position with pillow under the abdomen, sitz bath, ambulation, mild analgesics (Ibuprofen & naproxen) up to 30 mins before breast feeding
BUBBLE HE (B) assessment:
Breast
Uterus
Bladder
Bowels
Lochia
Episiotomy (perineum & hemorrhoids)
Homans sign (legs)
Emotions
Bonding
When do the breast begin to fill and what do they fill like?
Day 3, full, tight an heavy
When does engorgement occur?
Day 4
What prevents milk production?
No nipple stimulation, bra and ice packs
What are normal findings on the breast assessment?
-Flat, everted, inverted nipples
-Tissue is soft, filling and firm
-Temperature and color
What are normal findings on the uterus assessment?
-Involution: Describes the process by which the uterus returns to the nonpregnant state
-Mid-line, not deviated
-Firm
-Afterpains
-Assess in supine position
How to palpate the fundus:
-One hand above the pubic sympysis
-the other hand at the umbilicus, press inward and downward
What are normal findings for the bladder assessment?
-Spontaneous voiding within 6/8 hours
-Output: 150ml/hr
COLA: Color, odor, last void, amount
What are normal assessment findings for the bowel assessment?
-More active after childbirth
-Bowel movement around day 2 or 3
COLA: Color, odor, last void, amount
Nursing interventions to help facilitate normal bowel function:
-Drink fluids
-High-fiber
-Avoid ignoring urges & straining
-Early ambulation
-Stool softener and laxatives
What are normal assessment finding for lochia?
-Color: Rubra, Serosa, alba
-Amount: Scant, light, moderate, heavy (saturated in 1hr)
-Odor
-Clots v tissue
What are normal assessment finding for Episiotomy incision (perineal assessment)?
-No REEDA with incision (redness, edema, ecchymosis, discharge, WITH approximation)
-Assess for hemorrhoids, Tearing, Hematomas
Episiotomy care:
-Ice pack for 24/48 hours
-After, Sitz bath for 20 minutes
-Witch hazel pads
What is the first-line medications used to help with discomfort in postpartum?
NSAIDs
What position should be avoided for the 1st 3 weeks?
-Knee-chest position puts added pressure
+ Homan’s Sign:
Indicative of DVT
-Legs are extended and relaxed and kness are flexed
-Sharply dorsiflex the foot and if there’s resistance with discomfort, it is positive
What clinical manifestations are indicative of DVT?
Varicose veins, pain, pulselessness, warmth, edema, sensation.
How to prevent DVT:
-Early ambulation
-Active/passive ROM
-Avoid prolonged sitting
-Elevate legs
-Drink fluids
What 4 signs are looking for during emotional bonding?
-Talking to baby
-Holding the baby
-Gazing at the baby
-Pointing out features
What Hematological and Metabolic changes occur after pregnancy?
-Decrease in blood volume (lots of voiding)
-Estrogen Progesterone decrease and Prolactin is produced
What neurological changes occur after pregnancy?
Fatigue & discomfort
What changes occur to the renal system, fluids and electrolytes after pregnancy?
-Naturesis
-Diuresis (500 to 1000ml in one go)
What changes occur to the respiratory system after pregnancy?
Decrease in intra-abdominal pressure
What changes occur to the integumentary system after pregnancy?
Stretch marks
What changes occur to the Cardiovascular system after pregnancy?
-cardiac output returns to normal
What changes occur to the Immune system after pregnancy?
-WBCs are elevated
-RhD neg mothers who had a baby that is RhD pos, should recieve RhoGAM within 72 hours
-If non rubella immune, give MMR after birth
-Give Tdap after birth
What changes occur to the Reproductive system after pregnancy?
Menstrual occurs 6 to 8 weeks after
-Breast feeding mothers will return in 3 months
-Ovulation will follow
What changes occur to the GI system after pregnancy?
-Muscle fatigue
-Diastasis Rect-abdominis (modified sit ups and posture)
Postpartum nursing care for tubal ligation:
Air may enter the abdominal cavity which can cause should pain, encourage walking
Postpartum nursing care for C-section:
-BUBBLEHE
-Prevent DVT
-Promote bonding
-Foley discontinued after 12hrs
-Diet as tolerated
-Try NSAIDs over opiates
Education/intervention teaching for tubal ligation:
-Medicaid, need signed paper 30 days before prodecure
-NOT reversible
-Tubes are not tied but are removed
-Get consent
Nursing education for formula feedings:
-Handwashing
-Prepare as instructed
-Fomula should constituted with tested source of water
-Boiling will not get rid of harmful things
-Wash in hot, soapy water & air dry or dishwasher
-Do NOT microwave or prop bottle
-Burp frequently
-Can be fed cold, warmed or room-temp. Heat with pan or electric device
When should you throw out formula that was prepared?
24 hours
Benefits of breastfeeding for mother:
-Decreased risk of cancers, osteoporosis, & type 2 diabetes
-Uterine contractions occur due to the release of oxytocin (involution)
-Weight loss
-Budget-friendly
-infant bonding
Benefits of breastfeeding for baby:
-Enhanced immunity & maturity of the GI tract
-Decreased risk of SIDS, obesity, asthma, & type 1 diabetes
-Decreased pain
-Jaw development
-Protection againt childhood cancers
What conditions/procedures in risk of infection with c-section?
Prolonged procedures, choreo, DM, obese pt, poor diet. Clean with chlorahexidine wipes
What hormone makes the alveoli in the breast secrete milk?
Prolactin
When and what kind of milk is produced during stage 2 of milk production?
Occurs after delivery
The breat produce colostrum (sticky yellow milk)
What important things does colostrum contain?
Fats and immunoglobulin
When and what is occuring during stage 3 of milk production?
Occurs about 4 days after giving birth
Establishment and maintainance of milk supply
Milk appears thin and watery
What types of milk are produced what is their purpose for the baby?
-Foremilk: quinches thirst
-Hindmilk: satiety
What is the let down reflex?
Movement of milk into the large lactiferous ducts
-tingling in breasts
What can be done for women who do not experience the let-down reflex?
-Frequent stimulation of the breast
-Increased frequency of feedings
-Applying warmth to the breast
-Relaxing music
Should breast feeding ever be painful?
NO, should feel strong tugging sensation with occasional mild discomfort
What should be avoided regaruding nipple care?
Soap, breast creams, oils that contain Vitamin E
ONLY WATER or breast milk rubbed into the nipple
When is the optimal time to start breast feeding?
ASAP and/or within 1 hour after birth
Nursing education for breast feeding:
-Observe for hunger cues and act on it
-Show different positions
-Show correct latch
-Look to see if the bottom lip is “flanged”, and the cheek, nose and chin all touch the breast
-Never force the baby’s head, wait for infant to open their mouth
-1st week after birth, may feel after pains (multipara)
What signs show the baby has a good latch and is getting milk?
-Infant sucks and swallows
-2:1 or 1:1 suck/swallow
-milk can be seen at the corners of the mouth
What ratio is considered nonnutritive sucking?
5:1 suck/swallow
Infant-feeding readiness cues:
-Begin to stir
-Bob the head
-Hand-to-mouth or hand-to-hand movements
-Sucking, lip-smacking, licking
-Rooting
-Increased activity: arms and legs flexed and hands in a fist
How many wet diapers should we have a day?
6 to 8
How often does a breast-feeding baby need to eat?
2-3 hours, 15 minutes on each breast
Positions for breast feeding:
Cradle, cross-cradle, football and side-lying
Breast engorgement: definition and when it occurs
Excessive swelling and congestion in the breast
3/4th day
What are symptoms of severe engorgment?
Pain, tenderness, hardness, and warmth to the touch
How to fix engorgment:
-Express the milk via pump or feeding
-Warm soaks and ice after
-Massage
What meds are used for engorgment?
Ibuprofen before feedings
What causes sore nipples?
Poor latch
How to help fix sore nipples:
-Alt position
-Express milk and rub it in to the nipples
-Air dry and some sunlight
-Cabbage leaves
Fresh breast milk can stay out for how long?
4 hours room temp
How long can breast milk be refrigerated?
4 days
How long can breast milk be frozen?
6months to 1 year
How to thaw milk:
-In a collection container in the fridge
-Under warm water or water basin
-NEVER in hot water or room temp
What time-frame is considered an early PP hemorrhage?
within first 24 hours caused by uterine atony (most common)
What are signs of early PPH?
tachycardia, 15% drop in BP, decrease in O2 sats less than 95%
What time-frame is considered a late PP hemorrhage?
24 hours to 12 weeks
What are the 4 Ts?
-Tone
-Trauma
-Tissue
-Thrombin
What does a continuous trickle of bright red blood mean?
Lacteration (uterus will be contracted) or hemorrhage (uterus wiil be boggy)
What is a cardinal sign of a hematoma?
Unrelieved pain or pressure
What medications are we going to give for PPH?
-Oxytocin (pit): 20 U in 1000ml of LR. Bolus them
-Cytotec: rectally
-Hemabate: IM up to 8 doses. NO asthma due to bronchospasm & horrible diarrhea (give immodium)
-Methergine: IM. Do NOT administer if hypertensive
What is a common cause of late PPH?
retained placenta
What occurs during the takin-in phase?
The mother is consumed with relieving and reorganizing their birth experiences
What occurs during the taking-hold phase?
The mother feels better and is ready to assume the mothering role
What occurs during the letting go phase?
The mother starts to see the infant as separate from herself. Starts adapting to parenthood
What are the post partum blues?
A normal reaction to the dramatic changes that occur after birth and lasts for 2 weeks.
-R/t hormones
-Symptoms are mild and do NOT impair the ability to care for herself or the baby
What is uterine atony?
Failure of the uterine myometrium to contract and retract following birth
What is the hallmark sign of uterine atony?
Boggy uterus filled with clots and blood
What are risk factors for PPH?
-Prolonged or precipitous labor
-History
-Mutiple gestations
-large infant
-Polyhydramnios
-Trauma
-Chorio
-Retained placenta
-Agumentation or induction of labor with oxytocin
Nursing interventions for PPH:
-Vs
-Fundal massage
-Uterine location
-Palpate bladder
-Weight blood loss
-Measure how long it takes to saturate a pad
-LOC changes, pain level and behavior
-2 large bore IVs
-medications Oxygen 30 U
-Foley
-I & Os
-Oxygen 10 to 12L
What is it called in late PPH where the uterus cannot contract down due to retained placenta?
Subinvolution
What are ss of hypovolemic shock in PPH?
Tachycardia, restlessness, anxiety, pallor, cool clammy skin, hypotension
What is a sign of early hypovolemic shock?
tachycardia
What is a hematoma?
A localized collection of blood in connective or soft tissue under the skin
What is a hallmark sign and other signs of a hematoma?
acute unrelenting pain
-other: pressure in the rectal and or vaginal area, bluish color, tachycardia, hypotension, fullness.
Nursing interventions for hematomas:
-Listen to the patient’s complaints
-Vs
-Examine vaginal area
-NOTIFY PCP
-Ice for 12 hours
-pain meds
-after 12 hours sitz bath
-Drainage for hematoma over 5cm
-IV fluids
-Oxygen
-I&Os
-Foley
Superficial thrombosis:
In small veins they may appear like a hard knot
Care for superficial thrombosis:
Ted hose, ambulation, and keep the legs elevated while sitting
DVT:
Redness, swelling, heat, unilaterally in the calf.
Pallor & weak pulses
What position should a postpartum patient avoid?
Knee-chest
Who is at the greatest risk of thromboembolic disorders?
-Post-op CS
-Hx
-Smoker
-Obesity
-older women
Nursing interventions for thromboembolic disorders:
-Heparin for 3 mths
-NSAIDS
-Rest & elevation on the affected leg
-Compression socks
-Moist, warm packs
-leg circumference daily
T or F. All post partum women are in a hypercoagulable state
True
Sudden sharp, chest pain, SOB, and anxiety suggests…
pulmonary embolus
Nursing interventions for PE:
-ABCs
-Oxygen
-IV
-ICU
-Morphine
-family support
What is endometritis?
-Infection of the endometrium
Signs and symptoms of endometritis:
-Temp over 100.4 for over two days or a temperature of 101.6 in the first 24 hours
-Tachycardia
-Uterine tenderness
-suprapubic pain
-Subinvolution
-Malaise
-Foul-smelling lochia
Temp of ____F + is indicative of sepsis
102.2 F
Risk factors for endometritis
-Long labor
-ROM greater than 24 hours
-C-section
-+ GBS
-Operative vaginal delivery
-Prior STI
What is mastitis?
Infection and inflammation of the mammary glands.
signs and symptoms of mastitis:
-Fever, chills
-Pain and tenderness in one breast
-Warmth
-Aches
-Nipples with cracks, fissues or sores
-Flu-like
If there is abcess formation (pus) what should the nurse do?
Notify PCP
Nursing interventions for mastitis:
-Antibiotics
-Heat or cold
-Hydration
-Pain meds
-Proper latch
-hand hygiene
Education for mastitis
-Continue breast feeding on the affected side first for at least 15 minutes
-empty breast every 2-4 hours
What is PP depression?
-Major depressive disorder that develops within 4 weeks
-Characterized by a depressed mood or decreased interest or pleasure
Signs and symptoms of PP depression:
-depression
-disinterest
-lack of appetite
-insomnia
-restlessness
-anxiety
-hopeless
-inability to cope
-suicidal thoughts
Nursing interventions for PP depression:
-CBT & IPT
-therapy
-resources
-asking probing questions
-Meds: SSRIs, SNRIs, TCAs, Antidepressants, antipsychotics, mood stabilizer
What is PP psychosis?
Dramatic sudden onset within 24 hours of birth
Not associated with baby blues or depression
Risk factors for PP psychosis:
-First time mothers (who are older)
-Hx of bipolar and psychotic disorders
Clinical manifestations of PP psychosis:
-Auditory hallucinations
-Delusions
-Confusion
-Sleep disorders
-Suicide
-Homicide and infanticide
Nursing management of PP psychosis:
-Meds
-Therapy
-Electroconvulsive therapy
Discharge teaching for warning signs post partum:
-Temp
-Bleeding
-Pain: abdominal, breast, Perineal, Headache & epigastric (pre-eclampsia)
-Mood
-Leg cramps
Are after pains normal? Nursing interventions?
Yes. Apply counter pressure with a small pillow under the abdomen laying prone
Education/ discharge teaching for self care:
-Pericare
-Breast care
-Contraception
-Work, exercise, sex should only be resumed if they are cleared by the provider
Discharge teaching for infant care:
-Bathing
-Cord care
-Vaccinations
-Circumcision care
-Pericare
What are warning signs in infants?
Fever, refusal to feed, abnormal stooling, lack of urine output, fussy, lethargy
