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Nursing Semester 2 > Toni - Week 4 - Exam 2 > Flashcards

Toni - Week 4 - Exam 2 Flashcards

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1
Q

what does BUBBLE-EEE stand for?

A

Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy, Extremities, Epidural site, and Emotional Status; tells what is different in postpartum assessment than M-S assessment

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2
Q

Breasts: what are we assessing?

A

looking for cuts, cracks, fissures; trauma, tenderness, baby on breast with in minutes; engorgement, even in women that are bottlefeeding, as time goes on → can get engorged.

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3
Q

Uterus: what are we assessing?

A

Fundus and Incison (Absence of REEDA)

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4
Q

how can we best assess the fundus?

A

laying bed/patient flat for accuracy; knees up helps

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5
Q

what specifically are we assessing the fundus for?

A

firmness and location (in relation to umbilicus and midline)

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6
Q

what are we looking for with REEDA?

A

absence of redness, edema, ecchymosis (bruising), discharge, and approximation on incision sites

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7
Q

Bladder: what are we assessing?

A

making sure she’s voiding; void within 6 hrs of delivery; get her upright and to the BR before it’s an issue; standing orders for urinary catheters

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8
Q

Bowel: what are we assessing?

A

If post op, auscultate bowel sounds before fundal assessment; assess for flatus

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9
Q

Bowel: what foods should you avoid if mother is distended d/t gas?

A

avoid ice, carbonated drinks, apple juice until passing flatus

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10
Q

Bowel: what can stimulate flatus and BM?

A

Hot black tea and walking

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11
Q

Lochia: what are we assessing for?

A

how much she is bleeding, looking for clots, odor

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12
Q

Lochia: what is considered heaving bleeding?

A

1 pad per hr - 100mL (BEWARE: new pads can hold 500mL)

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13
Q

Lochia: what is the acceptable size of a clot?

A

the size of a walnut

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14
Q

Episiotomy: what are we assessing?

A

the perineum and any hemorrhoids

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15
Q

Episiotomy: what is the easiest way to assess the perineum?

A

have patient turn away from you and put one leg up; maybe have her face the door + shut curtain for privacy

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16
Q

Episiotomy: what do we do about hemorrhoids?

A

educate the woman on how to digitally reinsert them

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17
Q

What are two types of hemorrhoids?

A

external - hard, itchy, likely to bleed easily, can reinsert

internal - more than likely; prolapsing of vein

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18
Q

Treatment for hemorrhoids?

A

tucks, spray, reduced before replacing back inside, shower → reinsert → kegals

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19
Q

Extremities: what are we assessing?

A

Homan’s sign, edema, and DTRs

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20
Q

T/F: Homan’s sign is a good indication of a clot

A

FALSE; there is not evidence that supports Homan’s sign; more of something we’ve been doing so long, it makes us feel better

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21
Q

Why do we assess DTRs?

A

the reason we evaluate DTRs on all postpartum women is because 30% of the women WHO DEVELOP preeclampsia, have postpartum onset.

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22
Q

Epidural site: what are we assessing?

A

that the site is within normal limits - no discharge, inflammation, or redness

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23
Q

Emotional status: what are we assessing?

A

the bonding of the mother and baby; father and baby

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24
Q

what are the 7 postpartum cardiovascular changes?

A
  • cardiac output is ↑ for first 48 hours (women will notice heavy sweating and urination to get rid of fluid)
  • ↓ HR common the first week (40 - 60 bpm)
  • BP stable
  • Hgb + Hct reflects estimated blood loss (EBL)’
  • WBCS ↑ up to 25,000/mm3 = NORMAL
  • Hypercoagulable - risk of thromboembolism
  • Temp up to 38C (100.4F) normal first 24 hrs (if above 100.4 → call MD)
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25
Q

what is the maximum loss of blood loss for a vaginal delivery?

A

500mL; estimated

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26
Q

what is the maximum loss of blood for a C Section?

A

1000 mL; measured

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27
Q

what are all the risk factors that put a postpartum woman at risk for a clot?

A

hypercoagulable blood (↑ fibrin), ↑ cardiac output, immobility, obesity, surgery

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28
Q

what are the 2 breast changes postpartum?

A

colostrum first few days and engorgement

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29
Q

T/F even if a baby is not breast-feeding, we keep colostrum as first thing baby eats.

A

TRUE; it lines the baby’s gut and helps intestinal movement.

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30
Q

define engorgement.

A

breasts that are sore, swollen, full of milk, hot, red; difficult for baby to latch

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31
Q

What 5 interventions can help a lactating woman with engorgement?

A
  • breast feed, 1.5 - 2hrs
  • express breast milk (pump)
  • warm compresses (soften tissue easier to express milk)
  • ice packs
  • green cabbage leaf (green only, freeze + cut hole for nipple)
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32
Q

what 2 interventions can help a NON-lactating woman with engorgement? why?

A

• ice packs
• firm bra
- dries up within a week; can’t do anything that will express milk → will keep making more

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33
Q

vagina: what 2 changes happen postpartum?

A
  • thin, smooth walls

- dryness (dyspareunia)

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34
Q

perineum: what 4 changes happen postpartum?

A
  • edema
  • erythema
  • pain all common
  • episiotomy/laceration
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35
Q

pelvic floor muscles: what change occurs postpartum?

A

stretched, atonic (temporary)

36
Q

what 4 teachings can be done for postpartum vagina and perineum changes?

A
  • kegels (count to the count of 10 x 10 tid)
  • delay intercourse for 6 weeks or until complete absence of lochia (cervix is closed; we dont want anything in the open space → infection)
  • water soluble lubricant
  • contract butt (gluts) before sitting (↑ comfort)
37
Q

what are the 6 uterine changes postpartum?

A
  • involation (getting smaller)
  • contractions (1st time mother my not feel contraction )
  • after pains
  • placental attachment site heals
  • lochia occurs
  • cervix firm by the end of first week (umbilicus right after delivery, 1 cm less q day postpartum)
38
Q

what are the 3 stages of lochia?

A

rubra, serosa, and alba

39
Q

when does rubra occur and what does it look like?

A

day 1 - 3; dark red/brownish

40
Q

when does serosa occur and what does it look like?

A

day 3 - 10; pink

41
Q

when does alba occur and what does it look like

A

from day 10 up to 6 weeks; yellowish white + creamy

42
Q

what are the 3 urinary changes postpartum?

A
  • postpartum diuresis and diaphoresis
  • bladder (↓ tone, ↑ capacity)
  • full bladder displaces uterus
43
Q

what can the bladder changes (↓ tone/↑ capacity) cause?

A

urinary retention and infection

44
Q

when the bladder displaces the uterus, which direction does it go? what can this cause?

A

to the right; can cause:

  • uterine atony (interferes with contraction)
  • ↑ lochia
  • **make sure to empty bladder
45
Q

when should we expect a woman to void postpartum/?

A

expect void within 6 hrs; catherterize only if needed as ordered
***get her up, do peri care; may have to measure first two voidings

46
Q

how can we encourage urination?

A
  • privacy
  • running water
  • hand in warm water
  • slow exhale/blow through fist or straw
  • peppermint oil in specipan (fumes surround meatus = local relaxation)
47
Q

what 4 changes can we expect with the GI system postpartum?

A
  • significant hunger and thirst common (haven’t eaten in a while)
  • may not have BM for 2 - 3 days (natural diarrhea before labor)
  • increased risk for constipation and hemorrhoids
  • tears involving anal sphincter can occur (3rd or 4th degree tears)
48
Q

what are the 3 ways that tears can occur?

A
  • midline episiotomy
  • assisted delivery (forceps/vacuum)
  • large baby
49
Q

what are the 5 ways we can promote bowel elimination?

A
  • ambulation, fluids and fiber
  • stool softeners as ordered (q day if no BM then prn)
  • suppositories (NOT if laceration involves rectum)
  • encourage to obey BM urge; bear down normally ( you will not tear stitches out)
  • teach may gently reinsert small hemorrhoids into anus
50
Q

what are 3 interventions to promote bowel elimination post surgery (C-S or tubal ligation)

A
  • assess for flatus/distention
  • avoid ice, cold/carbonated drinks, and apple juice
  • encourage warm/room temperature liquids (black tea, warm blanket, walk q hour)
51
Q

when will a non-lactating mother’s menstruation return postpartum?

A

7 - 9 weeks

52
Q

when with a lactating mother’s menstruation return postpartum?

A

3 - 18 months

53
Q

what is menstruation delayed by?

A 
frequent feedings (on demand/8 - 12 feedings q day)
no supplementation (with H2O or formula)
54
Q

what should we teach woman about menstruation return?

A

ovulation may occur before first period; she could get pregnant

55
Q

what are 3 ways we can promote comfort to a woman experiencing after pains?

A
  • warm blanket
  • relaxation breathing
  • analgesics (ibuprofen + norco)
56
Q

what 4 ways can we promote perineum comfort?

A
  • ice pack
  • sitz bath x 20 min tid
  • contract butt before sitting
  • perineal care
57
Q

what 3 tools are used in postpartum peri care?

A
  • peri bottle (warm water)
  • blot dry (wiping could be painful)
  • peri meds (tucks + spray)
58
Q

what 5 ways can we promote comfort post C/S?

A
  • gentle C/S fundal checks
  • teach exhale when turning (relaxes)
  • position baby to avoid pressure on abdomen (football hold)
  • assist to lift baby from crib (can’t twist well)
  • may have had duramorph spinal (or PCA)
59
Q

what are the 3 steps to providing a gentle C/S fundal check?

A
  • first explain what you are going to do
  • have her inhale then press down over the fundus as she exhales with 1/2 fingers
  • if placement too high/low, repeat above
60
Q

what is RhoGAM?

A

an immunoglobulin given to block immune response and prevent maternal sensitization

61
Q

when is RhoGAM indicated?

A

for Rh- mom who has Rh+ baby (mixing of blood)

62
Q

what do we have to confirm for RhoGAM?

A
  • mom has negative indirect Coombs test (sensitivity test)

- baby has negative direct Coombs test (cord blood)

63
Q

when do we administer RhoGAM and where?

A

Administer 300mcg RhoGAM IM within 72 hours of birth

  • given in deltoid to ensure deposited in muscle
  • if goes into subQ not the same effect
64
Q

when is Rubella (MMR) indicated?

A

indicated if mother is non-immune to rubella (maternal title < 1:8)

65
Q

how much of the MMR vaccine do we give and when?

A

0.5 mL subQ just prior to discharge to avoid side effects in the hospital

66
Q

what are the side effects of MMR?

A

burning @ site and mild rash

67
Q

what do we want to teach with the MMR?

A

teach to avoid pregnancy for 4 weeks; can be administered at same time as RhoGAM

68
Q

what is bonding and when should it occur?

A

the attraction to newborn felt by parent; reaching out towards newborn; ideally occurs in critical period right after birth; also occurs in times of crisis

69
Q

what is attachment?

A

development of affectionate relationship between parent and newborn - “saying looks like dad, cooing”

70
Q

what are the different phases of maternal adjustment?

A

taking in, taking hold, and letting go

71
Q

when does taking in take place and what does it consist of?

A

1 - 2 days postpartum; mother is preoccupied with herself and baby, wants to talk about birth, explores infant

72
Q

when does taking hold take place and what does it consist of?

A

2 - 3 days postpartum; obsessed wit her body functions - mood swings (begin to take responsibility and control of motherhood

73
Q

when does the letting go take place and what does it consist of?

A

10 days - 6 weeks; mothering functions established, sees infant as unique person instead of a fantasy

74
Q

what are the four stages of partner psychological adjustment?

A

engrossment, expectations, reality, and transition to mastery

75
Q

define engrossment.

A

absorbed, preoccupied with baby

76
Q

define expectations.

A

not always based on reality

77
Q

define reality.

A

partner realizes expectations not realistic

78
Q

define transition to mastery.

A

partner makes conscious decision to take control and be more involved

79
Q

what is our role with the partner?

A

letting him help with infant care, treat family has triad with education

80
Q

what are 6 ways to promote adaptation to parenthood?

A
  • newborn with mother ASAP after birth
  • delay procedures that can impact bonding (assessment, bath)
  • 24 hr rooming in with partner
  • adequate pain relief
  • teach infant comforting
  • support parent and model infant care
81
Q

what are 4 methods we can teach the parents about infant comforting?

A
  • swaddling
  • shushing sound
  • rhythmic motion
  • holding with tummy pressure
82
Q

what are positive attachment behaviors from baby?

A

baby smiles, alert, cuddles, and consolable

83
Q

what are positive attachment behaviors from mom?

A

mom assumes en face position, makes direct eye contact, progressive maternal touch, speaks positively about newborn

84
Q

what are negative attachment behaviors from baby?

A

baby fussy/cries, stiff when held, inconsolable

- interferes with attachment; mom feels like failure

85
Q

what are negative attachment behaviors from mom?

A

mom expresses disappointment, uninterested in infant, does not hold baby close

Nursing Semester 2 (21 decks)

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