Test #2 Flashcards
What are the main components of a post partum assessment
BUBBLE-HEEE
BUBBLE-HEEE breast Uterus-check the fundus, address incision (if one) Bladder Bowels Lochia Episiotomy
Hemorrhoids
Extremities: homans sign,edema, DTR
Epidural site
Emotional status
When assessing a perineal incision What should you check for
REEDA
REEDA:
Redness Edema Echymyosis Discharge Approximation
What indicates milk coming into the breasts on an assessments
The breasts will feel more dense - usually about day 2
Correct position for someone to be in when checking the fundus
Lying flat on their back and knees bent up
When should you assess bowels
Auscultate prior to checking fundus
What are the cardiac changes in a post partum pt
⬆️ cardiac output Bradycardia Stable BP ⬆️ temp (up to 38c/100.4) Hypercoaguable state
What will H&H and WBC lab values look like in a post partum pt
H&H will reflect blood loss. 1gram= 500mL of blood loss
WBC can be up to 25,0000/mm3
what will tachycardia indicate in a post partum pt
hypovolemia
dehydration
hemorrhage
how long to the coagulation factors remain increased on a post partum pt
about 2-3 weeks
why is keeping a post partum woman bladder empty
because a full distended bladder will offset the uterus to either the left or right which inhibits the uterus from contracting and descending into the pelvis and thus increases the risk for post partum hemorrhage
also stagnant urine in the bladder can cause a UTI
what happens to a womans bladder after giving birth
-the bladder has decreased tone causing the bladder to be able to hold more urine
-increased capacity which
ultimately leads to increased risk for retention and infection
within how long after giving birth should a woman void
she should void within 6 hours
in what ways can you promote urination
- provide privacy
- running water
- put hand in warm water
- have her slowly exhale through her fist
- put peppermint oil in a specimen- the peppermint oil will help open up the urinary meatus
why would a post partum pt be at risk for constipation
- shes taking pain meds
- the slowed peristalsis d/t smooth muscle relaxation
- decreased intra-abdominal pressure
women who had an episiotomy or perineal laceration or hemorrhoids may be scared to push bowel movements so they don’t go to the bathroom
what hormone causes smooth muscle relaxation of the intestines
Progesterone
what is a significant GI change in post partum woman
they are more prone to constipation, hemorrhoids, may not have a bowel movement for 2-3 days
their appetite and thirst level increase d/t the NPO before birth but also the expenditure of energy during labor
what could cause tears of the anal sphincter
a midline episiotomy
assisted delivery-using a vacuum or forceps
a large baby
how can you promote bowel elimination
- administer suppositories and/or stool softeners
- get pt up and walking as soon as possible
- increase fluid and fiber intake
- educate pt about bearing down and the fact that if she bears down normally it will not rip out any sutures or tear any of her perineum.
what do you want to assess for after surgery (C-section/tubal ligation)
assess for presence of flatus and/or and distention
what can you do to aid in flatus
- encourage woman to drink warm or at least room temperature liquids
- AVOID ice, carbonated beverages, cold beverages, and apple juice
what is lochia
vaginal discharge that occurs after birth and continues for approximately 4-8 weeks. caused from uterine involution
what is the average lochia discharge amount
240-270mL/8-9oz
what are the 3 stages of lochia
- loch rubra-occurs 3-4 days after birth, deep red
- loch serosa- pinkish brown and is expelled 3-10 days post partum
- lochia alba- creamy white or light brown occurs from 10-14 days but can last up to 6 weeks
what are post partum vaginal changes
the walls of the vagina are thin and smooth
dryness occurs
pts experience dyspareunia
by what day will the fundus no longer be felt
by the end of day 10 it shouldn’t be able to be felt b/c it will have gone back into the pelvis
when does the vagina return to its approximate appropriate pre pregnant size
by 6-8 weeks after birth
-however it will always remain slightly larger than pre birth
when will the vagina begin to secrete moisture after birth
once menstruation returns
what can you do to relieve dyspareunia
use water soluble lubricants
what changes happen to the perineum post partum
the perineum is edematous and bruised and causing pain. decreased muscle tone and may contain a laceration
what happens to the pelvic floor after birth
it is stretched and restoration can take up to 6 months
what can you do to aid in vagina and perineum changes
- you can educate woman that if she is breast feeding it holds off menstration and therefore is contributing to the dryness and she can try water soluble lubricants.
- Teach her kegal exercises
- delay intercourse for 6 weeks
- if she had a tear or episiotomy- contract her buttock muscles before sitting so its not spreading the site of the episiotomy
- use a peri bottle for discomfort
- ice packs
- sitz baths
what can you do to relieve engorgment on a breast feeding pt.
- breast feed
- expressing milk to soften nipple
- warm compress
- ice packs
- place green cabbage leaf on breast
if the woman is not lactating what would you do to relieve engorgement
- ice packs
- firm bra
what may the woman feel that symbolizes the let down reflex
a tingling sensation in both breasts
what can help manage after pains
ibuprofen
why would the uterus not be involuting
- if the pt has a full bladder
- retained placental fragents
- infection
- problem caused from prolonged/difficult birth
- over distention of uterine muscles
- anesthesia (relaxes uterine muscles
- close childbirth spacing
why would a woman be experiencing more intense afterpains
-if she is breast feeding, the oxytocin released by the sucking reflex strengthens the contractions
would a drop or increase in blood pressure concern the nurse more
a significant increase especially if accompanied by a headache because it can be a sign of pre eclampsia which most woman are at greatest risk for during the post partum period
why would you not to expect to see a drop in hgb and hematocrit in a post partum pt if she is getting rid of the excess blood volume from pregnancy
because most of the fluid loss is plasma so the hematocrit and hgb should remain stable. if they do drop it can indicate hemorrhage
what should your pt expect post partum regarding the fluid loss she will be experiencing
diaphoresis (excessive sweating) is a common occurance because the body is trying to expel all the fluid
so waking up in a drenched sweat is considerably normal
what happens to estrogen and progesterone levels post partum
they decrease dramatically with the delivery of the placenta
what is associated with decreased estrogen
breast engorgement and diuresis of ECF
what will delay menstruation from returning
breast feeding
high levels of prolactin will delay ovulation by inhibiting ovarian response to FSH
when will menstration resume in a non lactating woman
7-9 weeks but can take up to 3 months
when will menstruation resume in a breast feeding woman
it depends on how often and how long the woman is breast feeding.
it can return anywhere from 3-18 months after birth
what measures can you take to promote perineum care
- ice packs
- sitz bath for 20 min
- contract the buttock before sitting if woman had an episiotomy
- have the woman blot dry- do not wipe
- use peri bottle while urinating to reduce discomfort
- use peri meds to help with the pain
what implementations can be used for after pains
- a warm blanket
- relaxation breathing
- analgesics (ibuprofen)
how would you perform a fundal check on a c-section pt
cup the bottom of the uterus, have the patient take a deep breath in and on the way out push down to find the fundus with one finger
what do you do if the pt has a boggy uterus and increased bleading
massage the uterus
what can the woman do to relieve pain while turning
breath out while turning
what can the woman do if holding the baby is causing her discomfort
- teach her the football hold so the baby is not on the abdomen
- use pillows to hold the baby while feeding to avoid pressure on the abdomen
if pt has duramorph spinal or post op PCA what should you assess
respiratory rate Q1H
Why would the WBC be elevated
Because the stress and labor of birth will cause leukocytosis
Why is knowing the post partum woman is in a hypercoaguable state important
Because this puts the pt at risk for a DVT especially if she had an epidural and is unable to be mobile
What does it mean if your post partum pt has a fever of 100.5 or greater
This can indicate post partum endometriosis and you should be calling the dr right away
where is the best place to hear a fetal heart beat
over the babys back- usually under the umbilicus unless the baby is breach then its above the umbilicus
what can interfere with external fetal monitoring
- maternal obesity
- excessive fetal/maternal movement
- fetus is in occiput posterior position(face up)
what position of the baby can cause the mother to have “back labor”
occiput posterior position
what can you do if you can’t hear the baby well with an external fetal monitor
you can use an internal fetal monitor- a fetal scalp electrode.
what is a necessity of performing a fetal scalp electrode
- you must be deemed competent before performing this skill
- the woman MUST be dilated 2 cm otherwise there is a risk of attaching the electrode to the cervix.
- membranes MUST be ruptured
what is the purpose of Leopold’s maneuvers
to determine the position of the baby
what is a toco dinomometer
a pressure device that monitors contractions- frequency and duration not intensity b/c depending on where the meter is placed the intensity changes
what can interfere with external monitoring of UCs
- maternal obesity
- excessive movement
why would you use continuous internal fetal monitoring
- for fetuses that are considered to be high risk including:
- multiple gestation,
- decreased fetal movement,
- abnormal FHR,
- maternal fever
- preeclampsia
- dysfunctional labor
why would you use an intrauterine pressure catheter
- for when a woman is induced
- not getting a good printout of UCs
- when labor is not progressing and we want to know why
what is the average FHR
110-160 during a 10 min period
what constitutes bradycardia in a fetus
a HR <110 for at least 10 min or more
what would be possible causes of bradycardia in fetus
-maternal hypotension
-fetal hypoxia(result from maternal hypotension)
/acidosis
-epidural
-analgesics
-uteroplacental insufficiency
-prolonged umbilical cord compression
what would be the possible causes of fetal tachycardia
- maternal fever
- fetal hypoxia-(heart is attempting to compensate for decreased o2- will see tachycardia followed by bradycardia d/t baby got tired)
- stimulant drugs
what is baseline variability
irregular fluctuations in the baseline FHR
what do we want baseline variability to look like
we want to see a jagged and unpredictable line- this means that the baby is responding to the environment. HR is increasing w/ movement and decreasing w/ relaxation
-moderate fluctuation- indicates fetus is well oxygenated
what does absent variability look like
smooth/minimal fluctuation of FHR
-indicates possible acidosis and uterpolacental insufficiency- baby is not getting enough O2
what can you do to improve uteroplacental blood flow to increase variability in FHR
- lateral positioning
- increase IV rate
- administer O2 via mask @ 8-10L/min
what are the four FHR changes
- accelerations
- early D Cells
- late D cells
- variable D cells
what are fetal HR accelerations
increase in above FHR baseline of at least 15 bpm for at least 15 seconds
-indicates fetal well being
what are interventions for FHR accelerations
none
we expect the HR to increase when moving etc.
just document
what do early Decelerations look like
begins and ends with uterine contractions
-the HR will start to drop as soon as the contraction goes up
what are nsg interventions for early D cells
none
it is caused from fetal head compression and may see it during pushing.
just chart it
what do Late Decelerations look like
The FHR drops after the contraction starts and returns to baseline after UC ends: the lowest point of HR occurs after peak of UC
usually come with minimal or absent variability
why are late decelerations concerning
- it is a sign of fetal hypoxia associated with uteroplacental insufficiency
- the baby has lost its ability to adapt to the contractions
what is the FIRST thing you do when you see a late deceleration
HELP THE BABY FIRST
- administer o2
- rotate mom
- hydrate mother via IV
- stop oxytocin if its infusing
what are variable decelerations
an abrupt deceleration with an abrupt return to baseline
what could be causing variable decelerations
umbilical cord compression
what are nsg interventions for variable decelerations
- oxygenate and rotate
- perform vaginal exam- you are looking for cord prolapse- if you feel the cord on the exam DO NOT TAKE YOUR FINGERS OUT: you want to do your best to push the babys head off the cord which may help the baby recover
what are nonpharmacologic comfort measures
- clean room(to mothers preference)
- soft lighting
- comfortable temp(some women are hot and A/C needs to be on)
- keep mom clean and dry
- mouth care-keep moist, ice chips
- remind mom to urinate
- position changes for comfort and to promote descending of fetus
- minimize distractions
- hydrotherapy
- hot/cold towels
- imagery(gate control theory)
- focal point
- massage/accupressure
- breathing techniques
what are advantages/disadvantages of IV opioids
rapid onset and short duration
however,
- may cause decrease in FHR variability
- decreased UC frequency and intensity
- newborn respiratory depression
what can reduce the effects of opioids on newborns
narcan
what can epidural analgesia cause
- maternal hypotension
- motor loss(unable to walk)
- urinary retention(have standing order for foley)
- prolonged 2nd stage of labor
- can blunt the urge to push
what should you administer prior to epidural
an IV bolus to maintain BP so it doesn’t bottom out.
usually an entire L over a short amount of time
how often do you assess vitals after epidural
Q15min from then on until delivery
what are the cardinal movements
changes in position of fetal head during labor to fit through maternal pelvis
when do you place a hot/cold towel on mom to help with contractions
right at the beginning of the contraction
what describes crowning
when the largest part of the head is coming through the perineum and does not slip back
-at this point the woman experiences “the ring of fire”
what indicates the placenta is ready to be delivered
there is a gush of blood- the gush of blood is the placenta detaching from the uterus
what will help expel the placenta
breastfeeding
because breastfeeding stimulates the release of oxytocin which stimulates uterine contractions
