WEEK 2- PP Fundamentals Part 2

Question 1

What is the criteria of the POSTPARTUM ASSESSMENT?

Answer 1

B reasts
U terine fundus
B ladder
B owel
L ochia
L egs
E pisiotomy/laceration/incision
E motional status
**Vital Signs**

Question 2

When assessing BREASTS…

Answer 2

• Inspect for size/symmetry/shape
• Palpate for degree of fullness (soft/full/engorged), firmness, tenderness, lumps, pain
• Even formula feeding clients*
• Inspect NIPPLES for redness, bruising, blisters, cracks, discomfort, everted/inverted or flat nipples

Question 3

When assessing UTERINE FUNDUS…

Answer 3

Ensure client is laying flat
1) HEIGHT - fundus descends 1 fingerbreadth each day
2/U (2 above umbillicus)
U/2 (2 below umbillicus)

2) LOCATION - midline or deviated
* Full bladder may push fundus R or L

3) TONE - firm or boggy
If boggy = gently massage to help muscles contract
Oxytocin can further aid in contracting the uterus

Question 4

When assessing BLADDER…

Answer 4

• Assess amount voided, fullness after void, burning/pain w/ voiding
• Assess for distention: physical signs of full bladder

Question 5

When assessing BOWEL…

Answer 5

• If no bowel mvmt, ensure client is passing gas

- Assess for presence of bowel sounds (all 4 quadrants), abdominal discomfort

Question 6

When assessing LOCHIA…

Answer 6

• Colour = rubra (red), serosa (pink-brown), alba (yellow-white)
• Amount = scant, mild, moderate, heavy
• Blood clots
• any foul ODOUR
• lochial vs non-lochial flow

Question 7

When assessing EPISIOTOMY/LACERATION/C-S INCISION…

Answer 7

REEDA

• Redness
• Edema
• Ecchymosis (bruising)
• Discharge
• Approximation
• Hemorrhoids (#, size, discomfort)
• Pain on scale of 1-10
• Ice therapy in first 24 hrs
• Sitz bath (after 24 hrs)
• Peri Bottle (after 24 hrs)

Question 8

When assessing EMOTIONAL STATUS…

Answer 8

• Coping (happy/sad/overwhelmed/level of fatigue/risk factors for PPD)
• Bonding/attachment behaviours
• Puerperal phases (taking in/taking hold/letting go)

Question 9

Expected Ranges for Vital Signs of PP client

Answer 9

T: 36-38C (Epidural causes slightly lower temps)
P: 60-100 bpm
RR: 12-20 breaths/min
BP: 120/80 watch for orthostatic hypotension

Question 10

4 Degrees of Laceration

Answer 10

Laceration = tissue spontaneously tears on its own

• 1st Degree = most superficial, NO SUTURES
• 2nd Degree = tears thru Perineal muscle
• 3rd Degree = tear continues thru perineal muscles to ANAL SPHINCTER
• 4th Degree = tears thru RECTUM

Question 11

Which client would experience more significant “afterpains”

Answer 11

Multip = uterus has already been stretched out + has to contract more to return to “normal” size

Question 12

Does breastfeeding stimulate endogenous or exogenous oxytocin

Answer 12

Answer: Endogenous

Oxytocin added to IV = exogenous oxytocin

Question 13

What are the Risk Factors of PPH (postpartum hemorrhage)

*HINT: 4 T’s

Answer 13

TONE:

• history of uterine atony (loss of tone)
• Overdistended uterus (multi-fetal pregnancy, large fetus LGA BABY)
• some meds
• fast or prolonged labour
• uterine subinvolution

TISSUE:

• retained placental fragments
• placental abruption
• placenta previa

TRAUMA:

• birth canal lacerations
• inversion or rupture of uterus
• assisted forceps/vacuum, or C/S birth

CLOTTING:

• bleeding disorders
• clotting disorders

Question 14

What are 3 types of Postpartum Complications?

Answer 14

1) PPH (postpartum hemorrhage)
2) PMD (perinatal mood disorder)
3) Infection

Question 15

What are the 3 types of PMD?

Answer 15

First 10 days = Postpartum “blues” is most common

Weeks to 1 yr = Postpartum depression (no psychosis)

2-8 Weeks = Postpartum depression (psychosis)

Question 16

What is the Nursing Role surrounding PMD?

Answer 16

• Screening: be a good active listener + demonstrate caring
• Health promotion/education/prevention
• Anticipatory guidance
• Safety assessment
• Support/reassurance: referrals + arrange mobilization support

Question 17

When assessing LEGS…

Answer 17

• signs of peripheral edema
• venous thromboembolism (red, tender, unilateral leg pain, localized edema
• ensure client is up walking around after birth

Question 18

What are the nursing interventions for PPH?

Answer 18

• Fundal massage to encourage contrxn
• Frequent vital signs
• Urinary bladder status
• Call for help! Stay with client
• Circulatory support = start/increase IV fluids + Oxytocin +O2

Question 19

Which one of the following statements is correct about uterine after pains?

A) Are less noticeable with subsequent births.
B) Are more noticeable 3-4 days postpartum.
C) Are more noticeable with breastfeeding.
D) Are less noticeable with exogenous oxytocin administration.

Answer 19

C) Are more noticeable with breastfeeding.

C is correct because breastfeeding causes endogenous oxytocin release.
A is incorrect because after pains are more noticeable with subsequent births as uterus has to work harder to remain firm (rubber band being stretched more than once analogy).
B after pains are less noticeable as time passes.
D is incorrect because after pains tend to increase with oxytocin administration.

Question 20

Which of one of the following symptoms is most concerning and therefore reportable to the most responsible health care provider?

A) Gush of lochia when performing fundal massage.
B) Gush of lochia when client changes position in bed.
C) Gush of lochia when client stands up from bed.
D) Gush of lochia when fundus palpates firm.

Answer 20

D) Gush of lochia when fundus palpates firm.

A, B and C are expected. D is reportable because it is non-lochial bleeding that needs to be evaluated.

Question 21

A client gave birth to a live singleton newborn 15 minutes ago. The birth was vaginal and the EBL (estimated blood loss) was approximately 1500 mls. Which one of the following would the nurse be most concerned about?

A) Temperature 37.3 C, Heart rate 118, Respirations 26, Blood pressure 88/40
B) Temperature 37.4 C, Heart rate 88, Respirations 22, Blood pressure 126/68
C) Temperature 38.0 C, Heart rate 110, Respirations 16, Blood pressure 110/80
D) Temperature 36.8 C, Heart rate 60, Respirations 18, Blood pressure 140/90

Answer 21

A) Temperature 37.3 C, Heart rate 118, Respirations 26, Blood pressure 88/40

A is most concerning because P and BP are abnormal and are symptomatic of the body compensating for the blood loss. These changes in vitals must be recognized promptly and nursing interventions employed to prevent/minimize hemorrhagic shock.
The T and HR are elevated in option C…potentially indicating infection but is not the most concerning set of vitals in the options provided.

Question 22

You are conducting a fundal and lochial assessment on a client who gave birth vaginally to Large for Gestational Age (LGA) baby 4 hours ago. You note that the client has a heavy amount of lochia on the peripad that was changed 1 hour ago, fundus is midline but boggy despite fundal massage, client appears pale, and reports feeling dizzy. Assessment of vital signs: BP is 80/50, HR 110bpm, RR 18 and temperature 37.0. What would be the most appropriate action for the nurse to take?

A) Lower the head of the bed and continue to monitor vital signs.
B) Assist client to bathroom to void and perform peri care.
C) Increase IV oxytocin rate and call for help.
D) Wake baby and put to breast to stimulate endogenous oxytocin release.

Answer 22

C) Increase IV oxytocin rate and call for help.

LGA baby increases risk for PPH. A is unsafe because PPH potential is unrecognized. B is unsafe because PPH potential is unrecognized, client is dizzy, being upright will contribute to hypotension and client will pass out and fall. D not a safe or timely response to imminent PPH. Baby to breast could be helpful if done much sooner as 1 of a few interventions to try to help minimize/prevent PPH.

Question 23

Your postpartum client, who has a right mediolateral (RML) episiotomy, tells you she does not want to use a sitz bath. The nurse would inform her that:

A) Sitz baths can help decrease perineal pain by promoting hyperesthesia.
B) Not using a sitz bath is a wise choice as they tend to promote infection.
C) None of us like a lot of things, but we have to do them anyway.
D) Sitz baths can help promote healing and comfort.

Answer 23

D) Sitz baths can help promote healing and comfort.

see text pg 572 + pre-clinical lab learning; discussed in class.
C- never to be said to a client!

Question 24

Which factor puts a client at higher risk for postpartum infection of the uterus?

A) Giving birth in the lithotomy position.
B) Rh isoimmunization.
C) Contracting chicken pox during pregnancy.
D) Rupture of membranes over 24 hours

Answer 24

D) Rupture of membranes over 24 hours

The first 3 options are not risk factors for postpartum infection (see pg 615 of text). The longer membranes are ruptured before delivery, increased risk for microorganisms to ascend and infect the uterus.

Question 25

The uterine involution process is expected to begin immediately after which event?

A) Administration of oxytocin.
B) Birth of placenta.
C) Suturing of perineum.
D) Initiation of breastfeeding.

Answer 25

B) Birth of placenta

Text pg 556 and discussed in class.
B-uterine involution begins immediately on its own once placenta is born. Oxytocin is part of evidence based active management standard of care to reduce risk of PPH.