Exam 3 Flashcards
involution
uterus returns to a pre-pregnant size, shape, and location; and the placental site heals
afterpains
severe cramp-like pains that are related to the uterus working harder to remain contracted and/or to the increase of oxytocin that is released in response to infant sucklng
How often do you assess the uterus after delivery of the placenta?
- q15 min for the first hour
- q30 min for the 2nd hour
- q4 hours for the next 22 hours
Why do you need the woman to void before assessing her uterus?
an over distended bladder can result in uterinine displacement and atony
Where do you place your second hand while assessing uterus?
just above the symphysis pubis
What actions should the nurse take if the uterus is boggy?
- massage the funds with the palm of the hand (until firm)
- reevaluate w/n 30 mins
- give oxytocin pre drys orders and notify dr if it does not respond to massage
metritis
an infection of the endometrial tissue
What does continued heavy bleeding with good fundal tone suggest?
- presence of a genitourinary tract laceration
- hematoma of the vulva or vagina
Pt teaching regarding afterpains
- occur w/n the first few days and last 36 hours
- empty bladder
- warm blankets
- ibuprofen
What are the 3 stages of lochia and what is the time frame?
- lochia rubra (day 1-3)
- lochia serosa (day 4-10)
- lochia alba (day 10)
lochia rubra
bloody with small clots
inc flow on standing or breastfeeding
lochia serosa
pink or brown color
inc flow during physical activity
lochia alba
yellow to white in color
scant amount
How much blood indicated hemorrhage?
one pad saturated in 15 mins
Pt teaching regarding perineum pain
- ice/cold sitz baths for the first 24 hours
- warm sitz baths after first 24 hours (2x a day for 20 mins)
- lie on side
- tighten gluteal muscles as sitting and relax once seated
- wear peri pads snuggly
- ibuprofen and/or topical anesthetics
- prevent infection (peri-bottle, change pads, and wash hands)
mastitis
- occurs 3-4 weeks post-birth
- d/t bacterial entry through cracks in the nipples, and is associated with milk stasis, stress, and fatigue
- s/s: fever, chills, malaise, flu-like symptoms, unilateral breast pain, and redness and tenderness in affected area
- tx: antibiotics, analgesics, rest, and hydration
Pt education for plugged milk ducts
- apply heat to the breasts to inc circulation and comfort
- supportive bra
- breast feed freq or express milk
WBC count after birth
increases to 25,000/mm after birth and returns to normal lvls within a week
How often do you assess VS of the mother post-delivery?
- Q15 min for 1st hour
- Q30 min for 2nd hour
- Q4 hours for the next 22 hours
- Q shift after the first 24 hours
What temperature will cause us to be concerned with infection?
After the first 24 hours, a temp greater than 100.4 on two occasions
Wha test do you administer for the Rh- woman who gave birth to a Rh+ child?
Coomb’s test
What is the minimum each void should be after birth?
150 mL
arab heritage
- wrap infant’s and at birth to prevent cold or wind rom entering the body
- call to pray is recited in the newborn’s ear
- male circumcision is a religious requirement.
- breastfeeding is delayed 2-3 days
chinese heritage
- preg and childbirth are women’s business
- postpartum care inc 1 month of recovery
- eat yang foods and avoid drinking and touching cold water
- family and relatives care for the newborn so woman can rest
filipino
- mother is major diocesan maker w/ health, children, and finances
- older relatives share in the responsibility and discipline of younger family members
- woman and her infant remain at home for the first 4 weeks except to go to drs
hindu
- home remedies during pre and postpartum
- birth of son vs daughter
- exposre to cold air is considered dangerous
- mother and infant undergo purification rites on the 11th day post-birth
- prescribed foods to eat and avoid when breastfeeding
japanese heritage
- mother sleeps with child until 10 years old
- babies aren’t allowed to cry; women constantly hold their babies
- women return to mother’s home during last 2 months of pre and stay 2 months post-birth
- women do not bathe, shower, or wash their hair for the 1st month post-birth
mexican
- women care for children and the home
- cutting baby’s hair or nails during the first 3 months is believed to cause blindness or deafness
- women are discouraged from taking baths or washing their hair for 6 weeks post-birth
navajo indian heritage
- children may be named at birth, but it is not revealed until their first laugh
- infants are kept in cradleboards until they can walk
- taboo to purchase clothes for the baby before they are born
placenta is buried as a symbol of the child being tied to the land
newborn is given a mixture of juniper bark to cleanse their insides and dispel mucus
What are the 3 maternal phases?
- taking-in
- taking-hold
- letting-go
entrainment
newborn moves arms and legs in rhythm with speech patterns of an adult
subinvolution
uterus does not decrease in size and does not descend into pelvis
Risk factors for DIC
- abruptio placenta
- HELLP syndrome
amniotic fluid embolism
amniotic fluid embolism (AFE)
i. e. anaphylactoid syndrome
- amniotic fluid that contains fetal cells, lanugo, and veering enters the maternal vascular system and initiates a cascading process that leads to cardiorespiratory collapse and DIC
1st degree laceration
top layer of skin (vaginal, perineal skin tear)
2nd degree
addition of perineal muscles torn
3rd degree
the addition of external anal sphincter torn
4th degree laceration
addition of complete anal sphincter tear and rectal mucosa. you can also tear the urethra
What are the 3 phases of bonding?
- acquaintance phase (finger tip exploration, en face, responds verbally to sounds of infant)
- mutual regulation phase (adjustment btw needs of mother and needs of infant)
- reciprocity phase (mutually gratifying interaction)
What are the 3 maternal phases?
- taking-in
- taking-hold
- letting go
What are the 4 stages of maternal role attainment?
- anticipatory stage
- formal stage
- informal stage
- personal stage
postpartum blues
transient period of depression that occurs during the first few days after delivery and resolves without intervention in 10-14 days
How do you assess VS of the mother post-delivery?
- Q15 min for 1st hour
- Q30 min for 2nd hour
- Q4 hours for the next 22 hours
- Qshift after
Why is there diaphoresis with the mother after birth?
d/t decreased estrogen lvls. It helps the body to excrete the inc fluid that was accumulated during pregnancy (there should NOT be an elevation in temp)
Pt teaching regarding muscle soreness?
- icepack to the area for 15 mins
- heat to area
- warm shower
- pain analgesics
What should you tell the mother diet/fluid-wise for at home while recovering?
- inc fluids (2000-3000 mL)
- inc fiber and roughage intake (fruits, veggies, whole grain, and legumes)
- inc calories by 500 kcal if breastfeeding
When can sexual activity be resumed post-delivery?
- lochia has stopped
- perineum has healed
- woman is physically and emotionally ready
What is PPH by definition? (primary/secondary)
- blood loss greater than 500 mL for vaginal deliveries
- blood loss greater than 100 mL for c/s
- Primary PPH occurs w/n first 24 hours and is d/t uterine atony, lacerations, or hematoma
- Secondary PPH occurs after 24 hours and is d/t hematoma, sub involution, or retained placental tissue
Assessment for PPH
- VS q 5-15 min
- assess uterus and for bladder distention
- assess funds for degree of firmness
- assess loch for amount and for clots
- review labs (H&H)
S/S of PPH
- soft, boggy uterus
- saturation of peripad w/n 15 min
- bleeding is slow and steady or sudden and massive
- blood clots (bigger than a quarter)
- pale/clammy skin
- anxiety or confusion
- tachycardia
- hypotension
Nursing Care for PPH
- lie supine, perform uterine massage, admin oxytocin as orded
- give O2
- admin IV fluids (3L for ea 1L loss)
- admin blood products if ordered
- assist woman to void bladder
- express clots and weigh pads and linen to obtain accurate ant of blood loss
- ## if retained placenta> anticipate D&C
What are the major causes of PPH in order?
- uterine atony
- retained placenta
- lacerations
What ar the s/s of hematoma?
- severe pain in vaginal/ perineal area
- tachycardia and hypotension
- heaviness or fullness in the vagina, and/or rectal pressure
- swelling, discoloration, and tenderness in perineal area
When do menses return for non-lactating women?
7-9 weeks post birth but is usually anovulatory until the 4th cycle
s/s of mastitis
- hard, tender palpable mass
- redness in the area around the mass
- acute pain in affected breast
- temp elevation
- tachycardia
- malaise
- purulent drainage
nursing care for mastitis
- warm compresses to affected area
- admin andibiotics and analgesics as ordered
teach. .. - hand washing
- correct infant latch
- proper removal from breast
- air drying nipples after feedings
- health, diet and adequate fluids
- continue to breastfeed and express milk
What is REEDA?
Used to assess lacerations/incisions
- redness
- edema
- ecchymosis
- discharge
- approximation of edges of episiotomy or lacerations
s/s of infection of perineum
- erythema/redness
- heat
- swelling
- tenderness
- purulent drainage
- low grade fever
- inc pain at incision/laceration site
