Module 7 (Exam 1) ****2****

Question 1

Breast Assessment for Formula Feeding Mother

Answer 1

1. Assess fullness and firmness
2. Inspect for early indicators of mastitis

Question 2

Early indicators of mastitis

Answer 2

1. Inflammation
2. Erythema

Question 3

Nursing Interventions for Formula Feeding Mother

Answer 3

1. Manage lactation suppression by using a breast binder/compression, cold packs intermittently, and analgesics PRN
2. Attend to learning needs about formula preparation and infant feeding

Question 4

Uterine Assessment

Answer 4

1. Assess for tone and position
2. Support uterus above symphysis
3. Begin palpation at umbilicus, locate fundus, determine location above/below umbilicus
4. Determine position of uterus (left, right, midline)

Question 5

REEDA

Answer 5

Uterine Assessment for Post Cesarean Section - Incision

1. Redness
2. Edema
3. Ecchymosis
4. Discharge
5. Approximation

*Protect incision while palpating uterus

Question 6

Expectations of fundal height

Answer 6

1. 12 Hours postpartum at umbilicus
2. PP Days 1-10: 1 fingerbreadth per day
3. Day 10-14, fundal descent into pelvic cavity and it is no longer palpable
4. Lateral Deviation requires assessment of bladder

Question 7

Red Flags Fundal Assessment

Answer 7

1. Boggy Uterus: if uterus is not contracting, than mother will bleed
2. Large Clots >quarter size (<quarter>
   </quarter><li>Freeflow: Indicates laceration and requires immediate intervention</li><li>Priority intervention is fundal massage - if fundus does not stay contracted after massage, there could be more issues</li>

</quarter>

Question 8

Nursing Interventions Bladder Assessment

Answer 8

1. Encourage frequent voids
2. Palpate bladder if uterus is high or deviated
3. Investigate frequency, volume, dysuria

Question 9

Nursing Interventions: Bowel Assessment

Answer 9

1. Balance activity with rest
2. Freqent, early ambulation astolerated
3. Auscultate bowel sounds
4. Palpate for abdominal tone and distention
5. Investigate tolerance of food and fluid and indicators of return to normal function

Question 10

Lochia Rubra

Answer 10

• DOD-PP Day #3
• Moderate amount, dark red, fleshy earthy odor
• Red Flags: Large clots, saturation >1 pad per hour

Question 11

Lochia Serosa

Answer 11

• PP day #4-10
• Moderate to light amount, pink to brown color
• Red Flags: Excessive amount, foul odor, reveral to rubra

Question 12

Lochia Alba

Answer 12

• Remainder of puerperium, may subside at 4-6 weeks PP
• Light to scant amount, creamy white
• Red Flags: Excessive amount, foul odor, reversal to rubra or serosa

Question 13

Episiotomy

Answer 13

• Perineal incision: straight (median) or 45 degree angle (mediolateral)
• Inspect for REEDA

Question 14

Lacerations/Perineal Integrity

Answer 14

• Inspect for bruising, hemorrhoids
• Investigate developing hematoma

Question 15

Nursing Interventions: Perineal Integrity

Answer 15

1. Support comfort and healing
2. Peri bottle
3. Intermittent ice packs for the initial 12-24 hours
4. Sitz bath after 24 hours
5. Topical anesthetic agents
6. PO analgesics

Question 16

Homan’s Sign

Answer 16

Thrombophlebitis

1. Dorsiflexion of foot elicits calf pain (positive Homan’s sign)
2. Indicates deep vein thrombosis
3. Superficial thrombophlebitis
   
   1. Erythema, warmth, tenderness
   2. Sometimes cool, pale, veins close to surface
4. PREVENTION: Early/frequent ambulation

Question 17

Factors that slow/retard involution

Answer 17

1. Placenta parts lingering
2. Blood clots
3. Infection

Question 18

Rationale for obtaining hct and hbg values after 24 hours PP

Answer 18

1. Diuresis and excretion of extracellular fluid may cause hemocentration
2. Rehydration assures more accurate values on PP day #2

Question 19

First-Degree Laceration

Answer 19

Involves the superficial vaginal mucosa or perineal skin

Question 20

Second-Degree Laceration

Answer 20

Involves the vaginal mucosa, perineal skin, fascia, and muscles of the perineum

Question 21

Third-Degree Laceration

Answer 21

Same as second degree lacerations but extends into or thorugh the external anal sphincter

Question 22

Fourth-Degree Laceration

Answer 22

Extends through the anal sphincter and into the rectal mucosa

Question 23

Prolactin

Answer 23

1. Secreted by the anterior pituitary
2. Responsible for milk synthesis

Question 24

Oxytocin

Answer 24

1. Secreted by the posterior pituitary
2. Responsible for the milk-ejection or let-down reflex

Question 25

Assessment that let-down reflex has occurred

Answer 25

Tingling sensation, warmth, sppearance of milk at nipple pores

Question 26

What body fluids can transmit HIV/aids?

Answer 26

blood, semen, amniotic fluid, vaginal secretions, colostrum and breast milk