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NURS 2910 > Postpartum Assessment and Nursing Care of the Newborn > Flashcards

Postpartum Assessment and Nursing Care of the Newborn Flashcards

1
Q

History terms of pregnant women

A
  • Gravida and para
  • Prenatal care
  • Blood type
  • Rubella Status
  • Last Tdap
  • Labor type
  • Medication use
  • Alcohol or drug use
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2
Q

Involution of the uterus

A
  • uterus moves down one finger each day
  • three processes> contradiction, catabolic processes, regeneration
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3
Q

Descent of the uterine fundus

A
  • At end of 3rd stage is 2cm below the umbilicus, then returns to umbilicus or 1 above within 12 hrs of delivery
  • decrease 1cm per day
  • 14 days after childbirth the fundus should no longer be palpable
  • afterpains/ uterine contractions may cause discomfort
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4
Q

Uterine Contradictions

A
  • necessary to achieve hemostasis at the placental site
  • Stimulated by release of oxytocin
  • Administration of exogenous oxytocin
  • Breastfeeding
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5
Q

The more kids you have the worse cramps you get T or F

A

True

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6
Q

Lochia

A

Vaginal Discharge

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7
Q

Lochia Rubra

A
  • 1-3 days
  • bloody, red/brown
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8
Q

Lochia serosa

A
  • 4-10 days
  • pink/ brown
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9
Q

Lochia alba

A
  • 11-21 days
  • white/ cream/ light yellow
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10
Q

Soaking up a pad in an hour or less is good T or F

A

FALSE, it is BAD

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11
Q

Lacerations of the Birth Canal

A
  • perineum, 1st, 2nd, 3rd, 4th degree
  • periurethral area
  • vaginal wall
  • cervix
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12
Q

Perinueum tears

A

Perineal lacerations are classified in degrees to describe the amount of tissue involved

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13
Q

Periurethral area tear

A
  • A laceration in the area of the urethra may cause women difficulty urinating after birth
  • An indwelling catheter may be necessary for a day or two
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14
Q

Vaginal Wall tear

A

A laceration involving the mucosa of the vaginal wall

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15
Q

Cervix tear

A

Tears may be a source of significant bleeding after birth

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16
Q

1st degree tear

A

involves the superficial vaginal mucosa or perineal skin

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17
Q

2nd degree tear

A

-involves the vaginal mucosa, perineal skin, and deeper tissues, which may include fascia and muscles of the perineum
- MOST COMMON

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18
Q

3rd degree tear

A

Same as second-degree lacerations but involves the anal sphincter

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19
Q

4th degree tear

A

Extends through the anal sphincter into the rectal mucosa

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20
Q

Additional system changes

A
  • resumption of ovulation/ menstruation
  • Lactation
  • Urine output
  • Coagulation> blood clots(DVT)
  • Loss of hair
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21
Q

BUBBLEEE

A

-Breasts & nipples
- Uterus
- Bladder
- Bowel
-Lochia
- Episiotomy/ perineum/ epidural site
- Extremities
- Emotional Status

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22
Q

Breast and Nipples

A

-Delivery of placenta causes a surge in prolactin levels and stimulates milk production
- the condition of breasts
- comfort
- assessment of latch-on if breastfeeding
- good fitting bra

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23
Q

Uterus

A
  • uterus/ fundal assessment
  • height, midline, firm
  • encourage patient to void before assessment
  • Assess uterine pain and other comfort measures
  • Uterus should be at the umbilicus after delivery and decrease about a centimeter everyday
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24
Q

Bladder

A
  • ensure empty bladder
  • look for infections
  • increased diuresis
  • look for signs of a distended bladder
  • bladder discomfort/ bulge
  • excessive lochia
  • frequent voiding may be a sign of urinary retention and overflow
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25
Q

Bowel

A
  • Potential constipation
  • hemorrhoids
  • dehydration
  • laceration
  • immobility
  • fear of pain
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26
Q

Lochia

A
  • volume of lochia flow according to the amount of flow on a perineal pad after 1-3 hours
  • scant: <2-5cm
  • light: 2.5-10cm
  • Moderate: 10-15cm
  • Heavy: saturated within 1 hr
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27
Q

Extremities

A
  • Thrombophlebitis
  • most likely lower extremities
  • dependent edema
  • prevent with early ambulation
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28
Q

Emotional State

A
  • baby blues
  • Attachment difficulties
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29
Q

Episiotomy/ perineum/ epidural site

A
  • Perineum> inspect with the woman lying on her side
  • assess and evaluate episiotomy/ laceration
  • Assess anal area as well for hemorrhoids
  • Check incision
  • assess for healing, approximation, discharge, and swelling
  • provide comfort measures
  • teach proper care of incisions
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30
Q

comfort measures

A
  • ice packs
  • baths
  • peri care
  • topical medication
  • sitting measures
  • analgesics
  • hot pack
  • massage/ touch
  • guided imagery
  • relaxation
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31
Q

Postpartum Warning Sign

A
  • fever > 100.4
  • foul-smelling lochia or unexpected change in color
  • large blood clots
  • severe headaches, blurred vision
  • calf pain> could be DVT
  • swelling, redness, or discharge at sites
  • depression and or mood swings
    -shortness of breath
32
Q

Cesarean Birth

A
  • purpose: to preserve the well-being of the mother and the fetus
  • can be planned/ scheduled
  • same assessments for C-birth patients except some postoperative care
  • percentage is higher in the US
33
Q

Postpartum Psychological Adjustment: Bonding

A
  • skin to skin> up for an hour after birth
  • Fatigue/ feeling overwhelmed
  • infant bonding
  • first period of reactivity
34
Q

Postpartum Psychological adjustment: Attachment

A
  • process by which an enduring bond to a child is developing through pleasurable, satisfying parent-child interactions
  • begins in pregnancy
  • Signs of reciprocal attachment behavior> eye contract, tracking parent, grasp/ hold fingers, entrainment
  • rooting/ latching
35
Q

Becoming Acquainted

A
  • maternal touch
  • en face, fingertipping, enfolding
  • verbal behaviors
  • call infant by name, mothers speak in high pitches
36
Q

Puerperal Phases

A
  • taking- in phase
  • taking-hold phase
  • letting-go phase
37
Q

Taking-in phase

A
  • first couple days
  • mother is focused on her own need for food and sleep
  • passive dependent behaviors
  • Making the birth a reality
38
Q

Taking-hold phase

A
  • Taking care of newborn
  • become more independent and concerned for her self-care
  • shifts attn to the newborn
  • great timing for treaching
39
Q

Letting-go phase

A
  • New role phase
  • relinquishes her previous roles
  • adjusting to disappointments
  • parents let go of ideals and fantasies
40
Q

Factors that affect adaptation

A
  • discomfort or pain
  • chronic fatigue
  • knowledge of infant needs
  • expectations of newborns
  • previous experience with newborns
  • maternal temperment
41
Q

postpartum blues

A
  • mild depression
  • affects 70-80% of new mothers
  • begins in the first week postpartum
  • should not last more than 2 weeks
  • must be distinguished from post partum depression or psychosis
42
Q

Initial newborn assessment

A
43
Q

APGAR Score

A

A- Appearance(color)
P- Pulse(Heart Rate)
G- Grimace(irritability)
A- Activity(muscle tone)
R- Respiration
- 0,1,2 score
- closer to ten the better and less distress

44
Q

When is APGAR Score assessed?

A
  • 1 minute after birth and 5 minutes after birth
45
Q

Why do nurses administer vitamin K

A
  • newborns have no intestinal flora needed to produce vitamin K
  • Helps with clotting
46
Q

Prevention of eye infections

A
  • prophylactic eye ointment erythromycin
  • prevents ophthalmia neonatorum
  • required by law in most states
47
Q

Initiation of first feeding

A
  • encourage the mother to breastfeed within the first hour of life, during first period of reactivity
  • Bottle-fed babies may wait 4-5 hours before the first formula is given, during second period of reactivity
48
Q

Facilitation of parent-infant attachment

A
  • eye to eye contact during the first hour
  • unlimited contact in first few hours
  • skin to skin
  • mother and father involved in first interaction
  • do all cares in room
49
Q

Behavioral patterns of newborns

A
  • first period of reactivity
  • period of decreased responsivness
  • second period of reactivity
50
Q

First period of reactivity

A
  • birth/30 minutes to 2hrs after birth
  • newborn is alert, moving, may appear hungry
51
Q

period of decreased responsivness

A
  • 30-120 minutes old
  • period of sleep or decreased activity
52
Q

second period of reactivity

A
  • 2 to 8 hours
  • newborn awakens and shows an interest in stimuli
53
Q

Respiratory Adaptations for Newborns

A
  • expansion of lungs, surfactant
  • resp. are shallow and irregular
  • 30-60 breaths/ minute
  • periodic breathing
54
Q

Routine Shift assessment

A
  • check head/ fontanels
  • Activity/ muscle tone
  • voiding/ stooling
  • bowel sounds
  • color, temp, integrity of skin
  • vitals
  • genitalia/ extremities
  • pain score
  • hygiene
  • length/ weight
55
Q

Methods of heat loss in infants

A
  • convections
  • radiation
  • evaportation
  • conduction
56
Q

Convection

A

loss of heat to the cooler air currents(fan)

57
Q

Radiation

A

transfer of body heat to a cooler solid object nearby(cold window)

58
Q

Evaporation

A

Loss of heat through conversion of a liquid to a vapor(bath)

59
Q

Conduction

A

Loss of heat to a cooler surface by direct skin contact(unwarmed blanket)

60
Q

Rooting Reflex

A

Infant opens mouth and turns head toward anything that touches its cheek

61
Q

Moro Reflex

A

Startle reflex

62
Q

Grasp Reflex

A

-any object placed in its hands will be grasped and then let go

63
Q

Tonic Neck reflex

A

the infant assumes a fencing position, while on the back it rotates the head to one side and extends the arm and leg it faces

64
Q

Walking reflex

A

tries to walk, step by step when held up right with legs hanging down

65
Q

Babinski reflex

A

infant hyperextends and fans toes when foot is stroked

66
Q

Plantar reflex

A

causes toes to curl inward and downward

67
Q

Newborn screening after 24 hours

A
  • bilirubin testing
  • newborn metabolic screen
  • hearing and screening
  • CCHD screening-critical congenital heart disease
68
Q

Metabolic screening

A
  • Have to wait 24 hrs after birth
  • identifies babies who may have certain inborn errors of metabolism
  • drop of blood obtained from baby’s heel 24-48 hrs of life
  • if diagnosed and treated early, development delays, sever illness, and death can be prevented
69
Q

hearing screening

A
  • # 1 birth defect
  • 90% of deaf/impaired newborns are born to hearing parents
  • early detection facilitates early treatment
  • infants who fail screening need to be further check by doctor
70
Q

CCHD Screening

A
  • pulse/ ox symmetry
  • R hand & 1 foot> fetal circulation
  • normal range is 95% +/- 3%
  • can decrease morbidity
71
Q

Hep B vaccine

A
  • received in the hospital soon after birth
  • the first dose can also be given up to 2 months
  • usually received before going home or at first dr visit
72
Q

Hypoglycemia in the newborn

A
  • Physiologic signs
  • Behavioral signs
  • Other signs
    < or equal to 45
73
Q

Physiologic signs of hypoglycemia in newborn

A
  • jitteriness
  • poor muscle tone
  • sweating
  • resp difficulty
  • low temperature
  • tachycardia
  • tachypnea
74
Q

Behavioral signs of hypoglycemia in newborn

A

-high-pitched cry
- lethargy
- irribility
- poor sucking
- grunting

75
Q

Other signs of hypoglycemia in newborn

A
  • Seizures
  • Coma
  • Cyanosis
  • Apnea
  • low temperature
76
Q

Jaundice

A
  • yellowing of skin
  • occurs in 60% of babies

NURS 2910 (16 decks)

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