Test #4 - Rest & Exercise/Oxygen Need

Question 1

What are some items that provide relief for hemorrhoids?

Answer 1

• Sltz baths
• Topical anesthetic ointments
• Rectal suppositories
• Witch hazel pads

Question 2

What are some relief items of afterpains?

Answer 2

Positioning (prone position)

Analgesia administered an hour before breastfeeding

Encourage early ambulation - monitor for dizziness and weakness

Question 3

What are some items to teach about postpartum medications?

Answer 3

Postpartum patient may need medications to promote comfort, treat anemia, immunize, and prevent development of antigens (in nonsensitized Rh-negative woman)

Postpartum patients should be informed about name of medication, expected action, possible side effects

Nurse must review safety measures with medications

Question 4

What are some items to remember about rest postpartum?

Answer 4

Organize nursing care to avoid frequent interruptions, educate new mother that fatigue may persist for several weeks

Mother should be encouraged to rest when baby rests

Mother may need to make adjustments at home and work

Question 5

What do you need to teach about ovulation and menstration for the postpartal woman?

Answer 5

• Menstruation returns between 6 and 10 weeks after birth in nonlactating mother. Lactating mothers may begin ovulation returns 3-6 months
• Return of ovulation and menstruation in breastfeeding mother is prolonged related to length of time breastfeeding continues

Question 6

What do you need to teach them about sexual activity post partum?

Answer 6

Sleep deprivation, vaginal dryness, and lack of time together may impact resumption of sexual activity

Usually sexual intercourse is resumed once episiotomy has healed and lochia has stopped (about 6 weeks)

Breastfeeding mother may have leakage of milk from nipples with sexual arousal

Question 7

What are some items to remember about contraception post partum?

Answer 7

Information on contraception should be part of discharge planning

Nursing staff need to identify advantages, disadvantages, risk factors, any contraindications

Breastfeeding mothers concerned that
contraceptive method will interfere with
ability to breastfeed - they should be given
available options

Question 8

What are some postpartum C-Section assessments?

Answer 8

Breasts must be assessed, assess location and firmness of fundus, lochia, and incision site

Assess Foley catheter in place, color, and amount noted - bowel sounds are checked: present, decreased, or minimal

Abdominal Incision

Question 9

What are some nursing care items for C-Section?

Answer 9

Cesarean birth is major abdominal surgery - if general anesthesia used, abdominal distension may cause discomfort

Turn every 2 hours, early ambulation, avoid carbonated beverages - may need enemas and stool softeners

Pulmonary infections may occur because of immobility and use of narcotics because of altered immune response

Encourage turn, cough, deep breath every 2 hours while awake until she is ambulating

Question 10

What are some pain and comfort interventions postpartum?

Answer 10

Administer analgesics within the first 24 to 72 hours - allows woman to become more mobile and active

Encourage visits by family and newborn, which provides distraction from painful stimuli

Encourage non-pharmacologic methods of
pain relief (breathing, relaxation, and
distraction) - encourage rest

Question 11

What happens for the attachment after a C-Section?

Answer 11

Physical condition of mother/newborn and maternal reactions to stress, anesthesia, and meds may impact mother-infant attachment

By 2nd or 3rd day, cesarean birth mother moves into “taking-hold period”

Emphasize home management and encourage mother to allow others to assume housekeeping responsibilities

-Stress how fatigue prolongs recovery and may
interfere with attachment process

Question 12

What do you need to do to prepare mom for discharge?

Answer 12

Preparation for discharge should begin when expectant mother enters birthing unit

Mother needs to be aware of signs of postpartum complications and should be aware of her self-care needs

Nurses should begin first by assessing knowledge and expectations of new mother and family

Nurse should be available to answer questions and provide support to parents

Nurse should review with new mother any information she has received regarding postpartum exercises, prevention of fatigue, sitz bath and perineal care, etc. -nurse should spend time with parent to determine if they have any last-minute questions before discharge

Question 13

What is postpartum hemorrhage defined as?

Answer 13

Blood loss that exceeds 500 ml after vaginal childbirth or 1000 ml after cesarean birth

Question 14

What are some risk factors for postpartum hemorrhage?

Answer 14

Induction/Augmentation

Uterine infection

Maternal malnutrition

Anemia

Gestational hypertention

History of hemorrhage

History of blood clotting problems

Question 15

What are some specific items that put a patient at risk for post partum hemorrhage?

Answer 15

Overdistention of uterus - from hydramnios, macrosomia, or multiple gestations

Grand muitip - old uterus with poor muscle tone

Anesthetics that relax uterus

Trauma - from use of mid forceps, intrauterine manipulation, forceps rotation - all could cause lacerations

Prolonged or rapid labor

Question 16

What are some items to do and remember when dealing with postpartum hemorrhage? (What to monitor/might not see)

Answer 16

You must monitor uterine tone and lochia flow carefully
-Where is fundus? Is it firm? Is there large clots?Bleeding?

Do not rely on VS changes (BP usually remains normal)

Changes in BP or pulse may not be seen until there has been a significant blood loss because woman is starting off with a higher blood volume from pregnancy

Question 17

What happens during early postpartum hemorrhage?

Answer 17

Occurring in the first 24 hrs after birth

Bleeding may be slow or heavy and massive

Uterine Atony

Trauma to birth canal during L&D

Abnormalities: Placenta accreta, inversion, retained placenta

DIC

Question 18

What is Uterine Atony?

Answer 18

Relaxation of the uterus

It won’t contract

Lack of muscle tone that results in failure of uterine fibers to contract firmly around blood vessels when the placenta separates

Most common cause of PP hemorrhage

Blood may be flowing out of uterus or pooling inside of uterus

Causes 80% to 90% of early PP hemorrhages

Question 19

What are some risk factors that can lead to Uterine Atony?

Answer 19

Overdistention

Dysfunctional or prolonged labor

Oxytocin augmentation, Use of anesthesia

Prolonged third stage of labor

Gestational hypertension

HX of hemorrhage, blood clotting problems, anemia

Retained placental fragments

Grandmultiparity

Placenta previa or Accreta

Question 20

What is retained placenta and what do you need to check for?

Answer 20

Retained Placenta sometimes caused by it being peeled off instead of waiting for it to separate naturally

It’s usually caused by massaging thefundus before separation occurs

Need to check the placenta and make sure it’s intact

Treatment -manual extraction, D&C, or hysterectomy

Question 21

What are some predisposing factors that lead to lacerations of the birth canal ?

Answer 21

Common cause of Hemorrhage (20%)

Includes: Vaginal, Perineal or Cervical Lacerations

Hematomas

Macrosomia

Rapid labor and delivery

Lacerations of Birth Canal - may be spontaneous or caused by instrument

The primary care provider usually checks for lacerations after a vaginal birth

Question 22

What is DIC (Disseminated intravascular coagulation)?

Answer 22

Causes blood coagulation problems

Clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII

Widespread external bleeding, internal bleeding, or both can result

Vascular occlusion of small vessels resulting from small clots forming in the microcirculation can also occur

Unusual bleeding i.e. spontaneous bleeding from the woman’s gums or nose may be noted. Petechiae may appear around a blood pressure cuff placed on the woman’s arm

Question 23

What can cause DIC?

Answer 23

May result from PIH

amniotic embolism

sepsis

abruptio placentae

prolonged fetal demise

excessive blood loss

Question 24

What are some assessment findings for DIC?

Answer 24

Excessive bleeding may occur from the site of a slight trauma

Symptoms also may include tachycardia and diaphoresis

(e.g., venipuncture sites, intramuscular or subcutaneous injection sites, nicks from shaving of perineum or abdomen, and injury from insertion of a urinary catheter)

Question 25

What are some lab tests for DIC?

Answer 25

Decreased levels of platelets, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin (the factors consumed during coagulation)

Fibrinolysis is increased at first but is later severely depressed. Degradation of fibrin leads to the accumulation of fibrin split products in the blood; these have anticoagulant properties and prolong the prothrombin time

Question 26

What are some nursing interventions for DIC?

Answer 26

Assess for signs of bleeding and complications from the administration of blood and blood products

Administering fluid or blood replacement as ordered

Protecting client from injury

Urinary output is monitored due to renal failure, must maintain OP of 30 ml/hr or more

Question 27

What is late postpartum hemorrhage?

Answer 27

Begins 24 hrs after birth, often 1-2 weeks after

Excessive activity can reopen the wound where the placenta was attached to the uterus

Question 28

What can cause late postpartum hemorrhage?

Answer 28

Retained placental fragments

Hematomas

Subinvolution - failure of uterus, and therefore, the placental site to reduce in size and shape

Infection

Question 29

What is late postpartum hemorrhage caused by subinvolution and what do you see and do?

Answer 29

Uterus remains higher in abdomen than expected and lochia stays rubra, or returns to rubra after progressing to serosa

Leukorrhea and backache may occur with infection

Treat with Methergine to contract uterus

Antibiotics if have infection

Question 30

What is late postpartum hemorrhage caused by hematomas and what do you watch for?

Answer 30

Hematomas - injury to blood vessels without trauma to tissues; may contain 250-500 ml of blood

Monitor for S/S of shock - weak, rapid, irregular pulse, pallor, cold moist skin

Causes severe pain and feelings of pressure

Question 31

What are some predisposing factors for hematomas?

Answer 31

PIH

Genital Varicosities

Pudendal block

Precipitous labor

Prolonged 2nd stage

LGA infant

Question 32

What are some assessments for hematomas?

Answer 32

Assessment findings include c/o severe pain at “stitches” (episiotomy) that doesn’t ease up

See tense, bulging, bluish, firm, painful mass at perineum or buttocks

Estimate size or measure to monitor for increase or decrease in size

Question 33

What are some nursing interventions for hematomas?

Answer 33

Treatment with ice if small vulvar

If large, need surgery to evacuate clot

Treat any infection with antibiotics

Monitor V/S

Foley-if unable to void

Replace blood lost

Question 34

What are some medical managements of late postpartum hemorrhage?

Answer 34

Prevention is best, you need to know who is at risk

Diagnostics and Lab

Bimanual uterine compression - if mom is hemorrhaging the uterus is elevated and held out of the pelvis by pushing the lower hand onto the abdomen right above the symphysis pubis and then massaging the fundus till firm

Fix cause - check for retained placental fragments, hematoma, possible uterine rupture, lacerations, suspect a coagulation problem if you observe that blood fails to clot (DIC)

Hysterectomy if all else fails

02 by mask so you can fully oxygenate the RBC’s

Question 35

What are some pharmacology to help with postpartum hemorrhage?

Answer 35

Oxytocin - infusion IV, 20 units in 1000 mis of LR or NS given over 3-4 hrs or bolused

Methergine - IM, PO- sustain uterine contractions-monitor for HTN & HA

Hemabate - used when uterine atony is not responding to other meds- N/V, fever, HA, diarrhea, and flushing may occur

Will need to medicate for pain of the contractions

Question 36

What are some nursing interventions for postpartum hemorrhage?

Answer 36

Assessment

Prevention of hemorrhage is best

Frequent fundal and lochia checks - q 10-15 min

Weigh pads before and after 500 mis = 1 lb 1 gm = 1 ml

Be aware of who is at risk for hemorrhaging

Turn mom over to check for blood pooled under buttocks

Any excessive bleeding massage the fundus and turn up the oxytocin infusion

Plan - Women at risk for hemorrhage need frequent assessments

Need to maintain IV and patency

T and C and keep ahead if blood is ordered

Question 37

What are some health promotions and teachings for discharge?

Answer 37

Discharge planning - often have early dismissals

Mom is in the “Taking-in” phase and not teachable so need to give her discharge instructions in written form

Teach client to report any return of bright red lochia after 4th PP day

S/S of infection which may cause delayed PP hemorrhage - Fever over 100.4, Foul smelling lochia, Flu like symptom

Teach them to conserve energy, get plenty of rest, find out who can come and help

Refer to social services if needed

Question 38

What is thromboembolic disease?

Answer 38

Pathophysiology: venous stasis from inactivity

• Pregnancy increases the risk for thrombosis formation from hyper-coagulability, venous stasis associated with the pressure of an enlarged uterus, and the decreased activity of the woman

Question 39

What is a Thrombus?

Answer 39

A collection of blood factors, primarily platelets and fibrin, on a vessel wall forming whenever blood flow is impeded

A partial obstruction of a vessel

If thrombus formed because of inflammation of venous wall, then tend not to move

If thrombus formed because of stasis of blood, it tends to move and become an embolus

Question 40

What is thrombophlebitis?

Answer 40

An inflammatory process in the vessel wall

A thrombus formation that may be due to inflammation in the vein wall

Tends not to move, just stays there

3-4 PP day with you’ll find:
- Tenderness, heat, redness, may have fever

Question 41

What are some S&S of Deep Vein Thrombosis?

Answer 41

S/S are often diffuse - difficult to DX

Obstruction of venous returnn causes edema of leg or ankle - decreased pedal pulses

Coolness and pale leg called “Milk Leg”

High fever, chills

Pain depending on location

Question 42

What are some clinical manifestations of DVT?

Answer 42

Positive Homan’s- pain with dorsiflexion

May not have + Homan’s but will have pain with calf pressure

Call and inform doctor and keep mom on strict bedrest

Do not massage calf of client with + Homan’s !!

Question 43

What do you want to assess for in a DVT?

Answer 43

Palpate pulses

Inspect the affected leg

Degree of discomfort, pain

Evaluate labs - clotting studies

Platelets

Question 44

What is some pharmacology for DVT?

Answer 44

Heparin IV for DVT

Coumadin PO when mom starts improving

Heparin usually discontinued when PT is 1.5-1.7

Stay on Coumadin for 2-6 months

Question 45

What are some preventions for DVT?

Answer 45

Activity, walking early during pregnancy and PP

Avoid prolonged sitting or standing

Support hose “

Adequate hydration

Teach mom to point toes toward her face

Avoid knee gatch, crossed legs

Promote venous return

Stop smoking

Question 46

What is a pulmonary embolism?

Answer 46

An undissolved substance travels from the venous circulation to the right side of the heart and the pulmonary artery and lodges there obstructing blood flow

Which leads to pulmonary hypertension and possible infarction (tissue death)

Types include thrombus (blood clot is usual type seen PP), fat embolism (after fracture of long bone), and air embolism. VERY serious problem

Foreign substance goes to right heart, out pulmonary artery, lodges there blocking blood flow to lung

CRISIS!

Question 47

What are some assessments for PE?

Answer 47

Sudden onset-acute chest pain

Sudden onset sweating

Pallor, cyanosis

Cough with or without blood

Dyspnea, SOB, tachycardia, tachypnea

Increased jugular pressure

Pressure in rectum

Apprehension-impending doom

Confusion

Hypotension

Auscultate friction rub on chest (rub thumb on a balloon)

Decreased breath sounds

Gallop heart rhythm

Question 48

What are some nursing interventions for PE?

Answer 48

Start treatment immediately!

IV fluids, 02, High Fowlers, VS, l&O

Support respirations

Question 49

What is some pharmacology for PE?

Answer 49

Demerol for pain

Aminophylline for bronchospasms Anticoagulants - Heparin Streptokinase, Urokinase - clot busters for fibrinolytic therapy

Lovenox

Question 50

PE Mnemonic

Answer 50