Test #4 - PP Safety & Security/F&E

Question 1

What is Involution?

Answer 1

• The rapid reduction in size of uterus and return to pre-pregnant state
• Exfoliation allows for healing of placenta site and is an important part of involution
• Enhanced by uncomplicated labor and birth – Complete expulsion of placenta or membranes, breastfeeding and early ambulation
• Uterus is at level of umbilicus within 6-12 hours after childbirth-DEC by one finger-breadth per day
• Uterus rids itself of debris remaining after birth through discharge called LOCHIA
• Uterine contractility is of most importance for this to occur

Question 2

What are some interventions to make sure involution has occured?

Answer 2

Monitor VS & Fundus every 15min for first hour, the every 30 for the next hour, then hourly for the next 2 hours, then every 8 hours

MORE FEQUENTLY if there is bogginess, position out of midline or heavy lochia flow

Assess BP within normal limits; NO hypotension

If boggy: Fundal massage then pitocin

Question 3

What are some Medications given if fundal massage and pitocin don’t work that promote involution?

Answer 3

Methergine – Given IM

0.2mg every 2-4 hours for a max of 5 doses
Given IV in life threatening situations ONLY
DO NOT give if mother is hypertensive
Contraindicated in women with: Severe renal disease, hypertension, thrombophlebitis, CAD, PVD, or sepsis before the 4th stage of labor.
SE: Nausea, Vomitting, Uterine cramping, hypertension, dyspnea, chest pain, seizures

Hemabate – Given IM

250 mcg given at 15-90 minute intervals; MAX total dose 2mg
Contraindicated in women with: Acute PID, cardiac, pulmonary, renal or hepatic disease.
SE: May cause uterine hypertonus if used with oxytocin, Nausea, vomiting, DIARRHEA (Stated in class), fever, chills, facial flushing, headache

Question 4

Methergine Chart

Answer 4

Question 5

Hemabate Chart

Answer 5

Question 6

Post Partum Assessment

BUBBLEHE Mnemonic

Answer 6

Question 7

What do you need to assess PP when pertaining to breast and uterus?

Answer 7

Breast: Assess if mother is breast or bottle feeding

Breast: Inspect nipples and palpate for engorgement or tenderness

Uterus: Determine firmness of fundus and ascertain position

Uterus: Correlate position with approximate descent of 1cm per day

Question 8

What do you need to assess PP when pertaining to Bowel and Bladder?

Answer 8

Bowel: Assess bowel sounds, flatus and distention

Bladder: Assess frequency, burning or urgency

Bladder: Palpate for distention – If so straight cath

Question 9

What do you need to assess PP when pertaining to elimination?

Answer 9

Intestines sluggish because of lingering effects of progesterone and dec muscle tone

Spontaneous bowel movement may not occur for 2-3 days after childbirth

Mother may anticipate discomfort because of perineal tenderness or fear of episiotomy tearing

Elimination returns to normal within 1 week

After cesarean section, bowel tone returns in few days and flatulence causes abdominal discomfort

Question 10

What do you need to assess for with the urinary tract PP?

Answer 10

Mother has increased bladder capacity, decreased bladder tone, swelling and bruising of tissue

Puerperal diuresis leads to rapid filling of bladder – Urinary stasis increases chance of urinary tract infection

If fundus is higher than expected on palpation and is not in midline, nurse should suspect bladder distention

Question 11

what do you need to assess PP when pertaining to the Lochia?

Answer 11

Changes: bright red, rubra, serosa, alba, clear

If blood collects and forms clots within uterus, fundus arises and becomes “boggy” (Uterine Atony)

Chart amount, color, and odor

Lochia Rubra

Red

1-3

Blood, fragments of flesh, and mucus

Lochi Serosa

Pink

3-10

Blood, mucus, invading leukocytes

Lochia Alba

White

10-14 (up to 6 weeks)

Largely mucus; Leukocyte count high

Question 12

When assessing the episiotomy PP what does REEDA stand for?

Answer 12

Redness

Edema

Eccymosis

Discharge

Approximation

Takes 4-6 weeks to heal

Ice packs for the first 12 hours

Question 13

What do you need to do for the hemorrhoids/Homan’s?

Answer 13

Assess for hemorrhoids

Use tucks pads, numbing foam

Extremeties:
Assess for pedal edema, redness and warmth
Check Homan’s sign

Question 14

What are some things to remember for the lactation assessment?

Answer 14

Breast begins milk production – Milk production is a result of interplay of maternal hormones

Takes 1-2 days for milk to come in

More stimulation=faster the milk is produced

Encourage fluids

Inc BP or PP hemorrhage leads to trouble with milk production

Smokers have low milk production

Question 15

What are some fluid & electrolyte tidbits PP?

Answer 15

• Fluid needs during the immediate postpartum period need to include postpartum diaphoresis
• A great deal of fluid may have been lost during labor
• Mom is hungry and thirsty and will drink large amounts of fluid-2000ml or more (WATER!!)
• C-Section patients started on clear liquids when they have bowel sounds

Question 16

What are some fluid volume deficit assessments?

Answer 16

Hypotension

Tachycardia

Changes in mental status

Dec or concentrated urine

Delayed cap refill

Dry skin/mucous membranes

Question 17

What are some F&E assessments PP?

Answer 17

I&O - Output often 2000-3000ml/24 hour

Check skin turgor and mucous membranes

Check for Homan’s (Think hypercoagulability)

Check for electrolyte imbalance – Headache, muscle twitching

Lab Values – HGB/HCT, ABG’s, Specific gravity

Question 18

What are some PP F&E interventions?

Answer 18

Monitor VS

Keep patent IV – Must void 3x before removing IV

Maintain quiet environment

Monitor involution of fundus (Weigh pads which 1ml=1g if ordered)