Module 7 (Exam 1) ****2**** Flashcards
Breast Assessment for Formula Feeding Mother
- Assess fullness and firmness
- Inspect for early indicators of mastitis
Early indicators of mastitis
- Inflammation
- Erythema
Nursing Interventions for Formula Feeding Mother
- Manage lactation suppression by using a breast binder/compression, cold packs intermittently, and analgesics PRN
- Attend to learning needs about formula preparation and infant feeding
Uterine Assessment
- Assess for tone and position
- Support uterus above symphysis
- Begin palpation at umbilicus, locate fundus, determine location above/below umbilicus
- Determine position of uterus (left, right, midline)
REEDA
Uterine Assessment for Post Cesarean Section - Incision
- Redness
- Edema
- Ecchymosis
- Discharge
- Approximation
*Protect incision while palpating uterus
Expectations of fundal height
- 12 Hours postpartum at umbilicus
- PP Days 1-10: 1 fingerbreadth per day
- Day 10-14, fundal descent into pelvic cavity and it is no longer palpable
- Lateral Deviation requires assessment of bladder
Red Flags Fundal Assessment
- Boggy Uterus: if uterus is not contracting, than mother will bleed
- 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>
Nursing Interventions Bladder Assessment
- Encourage frequent voids
- Palpate bladder if uterus is high or deviated
- Investigate frequency, volume, dysuria
Nursing Interventions: Bowel Assessment
- Balance activity with rest
- Freqent, early ambulation astolerated
- Auscultate bowel sounds
- Palpate for abdominal tone and distention
- Investigate tolerance of food and fluid and indicators of return to normal function
Lochia Rubra
- DOD-PP Day #3
- Moderate amount, dark red, fleshy earthy odor
- Red Flags: Large clots, saturation >1 pad per hour
Lochia Serosa
- PP day #4-10
- Moderate to light amount, pink to brown color
- Red Flags: Excessive amount, foul odor, reveral to rubra
Lochia Alba
- 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
Episiotomy
- Perineal incision: straight (median) or 45 degree angle (mediolateral)
- Inspect for REEDA
Lacerations/Perineal Integrity
- Inspect for bruising, hemorrhoids
- Investigate developing hematoma
Nursing Interventions: Perineal Integrity
- Support comfort and healing
- Peri bottle
- Intermittent ice packs for the initial 12-24 hours
- Sitz bath after 24 hours
- Topical anesthetic agents
- PO analgesics
Homan’s Sign
Thrombophlebitis
- Dorsiflexion of foot elicits calf pain (positive Homan’s sign)
- Indicates deep vein thrombosis
- Superficial thrombophlebitis
- Erythema, warmth, tenderness
- Sometimes cool, pale, veins close to surface
- PREVENTION: Early/frequent ambulation
Factors that slow/retard involution
- Placenta parts lingering
- Blood clots
- Infection
Rationale for obtaining hct and hbg values after 24 hours PP
- Diuresis and excretion of extracellular fluid may cause hemocentration
- Rehydration assures more accurate values on PP day #2
First-Degree Laceration
Involves the superficial vaginal mucosa or perineal skin
Second-Degree Laceration
Involves the vaginal mucosa, perineal skin, fascia, and muscles of the perineum
Third-Degree Laceration
Same as second degree lacerations but extends into or thorugh the external anal sphincter
Fourth-Degree Laceration
Extends through the anal sphincter and into the rectal mucosa
Prolactin
- Secreted by the anterior pituitary
- Responsible for milk synthesis
Oxytocin
- Secreted by the posterior pituitary
- Responsible for the milk-ejection or let-down reflex
Assessment that let-down reflex has occurred
Tingling sensation, warmth, sppearance of milk at nipple pores
What body fluids can transmit HIV/aids?
blood, semen, amniotic fluid, vaginal secretions, colostrum and breast milk
