week 5 COPY Flashcards

Question 1

Q

Postpartum physiological changes: Vitals

Expected findings
- Temp elevated up to 100.4 F for_____ hours after birth
- Afebrile after _____ hours
- Temp may continue to be increased for 24 hours after ______ comes in (low grade fever 99 F)
- BP slightly elevated or decreased?
- Bradycardia or tachycardia for 6-10 days?

Answer

A

Vitals
Expected findings
- Temp elevated up to 100.4 F for 24 hours after birth
- Afebrile after 24 hours
- Temp may continue to be increased for 24 hours after milk comes in (low grade fever 99 F)
- BP slightly elevated
- Bradycardia for 6-10 days

Question 2

Q

Postpartum physiological changes: Vitals

Unexpected/abnormal findings
- Temp > 100.4 F – we suspect ________
- low/high BP? - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety
- low/high BP? - we suspect r/t uterine hemorrhage, hematoma
- tachycardia/bradycardia? – we suspect r/t difficult labor and birth, hemorrhage, r/o fever (infection)
- marked tachypnea/bradypnea? – r/o respiratory disease and pulmonary edema

Answer

A

Unexpected/abnormal findings
- Temp > 100.4 F – we suspect infection
- High BP - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety)
- low BP - we suspect r/t uterine hemorrhage, hematoma)
- tachycardia – we suspect r/t difficult labor and birth, hemorrhage, r/o fever (infection)
- marked tachypnea – r/o respiratory disease and pulmonary edema

Question 3

Q

Postpartum physiological changes: Vitals

expected vs unexpected finding
- temp 100.1 F 12 hours after birth
- temp 100.1 F 36 hours after birth
- temp 99.1 F 24 hours after birth
- BP slightly elevated
- bradycardia 2 weeks after birth
- high BP
- temp 100.8 F 24 hours after birth
- low BP
- tachycardia
- tachypnea

Answer

A

E - temp 100.1 F 12 hours after birth
U - temp 100.1 F 36 hours after birth = should be afebrile within 24 hours
E - temp 99.1 F 24 hours after birth = low fever r/t milk coming in
E - BP slightly elevated
U - bradycardia 2 weeks after birth = should only be for 6-10 days
U - high BP
U - temp 100.8 F 20 hours after birth = too high to be considered expected
U - low BP
U - tachycardia
U - tachypnea

Question 4

Q

Postpartum physiological changes: Vitals

Unexpected/abnormal findings
- Temp > 100.4 F – we suspect ___________
- High BP - we suspect r/t ________, _________, ________, _________
- low BP - we suspect r/t ______, __________
- tachycardia – we suspect r/t ___________, _______________, r/o fever (infection)
- marked tachypnea – r/o ___________ and ____________

respiratory disease
pulmonary edema
infection
preeclampsia
HTN
difficult birth and labor
hemorrhage
renal disease
anxiety
uterine hemorrhage
hematoma

Answer

A

Unexpected/abnormal findings
- Temp > 100.4 F – we suspect infection
- High BP - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety)
- low BP - we suspect r/t uterine hemorrhage, hematoma)
- tachycardia – we suspect r/t difficult labor and birth, hemorrhage, r/o fever (infection)
- marked tachypnea – r/o respiratory disease and pulmonary edema

Question 5

Q

Postpartum physiological changes: Vitals

Unexpected/abnormal findings

High BP - we suspect r/t preeclampsia, essential HTN, renal disease, anxiety)

Treatment T/F
- tocolytic: Procardia
- oxytocin
- Labetalol
- aldomet
- magnesium sulfate
- prostaglandin
- aspirin

Answer

A

Treatment
- tocolytic: Procardia - relaxes muscles
- Labetalol - HTN med
- aldomet - HTN med
- magnesium sulfate - relaxes muscles, prevents seizures

Question 6

Q

Postpartum physiological changes: Cardiovascular

Expected findings
- cardiac output decrease/increase? – up to 30% for 2 weeks, back to normal levels by 6-12 weeks post birth
- increased/decreased urination?
- weight loss/gain?

Unexpected/abnormal findings
- pulmonary edema, cardiac problems, adventitious lung sounds (crackles) – body is failing to ___________

Answer

A

Cardiovascular

Expected findings
- cardiac output decline – up to 30% decline for 2 weeks, back to normal levels by 6-12 weeks post birth
- diuresis, increased urination, weight loss – body is decreasing extracellular fluid

Unexpected/abnormal findings
- pulmonary edema, cardiac problems, adventitious lung sounds (crackles) – body is failing to eliminate extra fluid

Question 7

Q

Postpartum physiological changes: Respiratory

Expected findings
- clear lungs
- non-labored breathing
- eupnea = normal breathing

Unexpected/abnormal findings
- tachypnea/bradypnea? – we suspect r/t fever or pain
- tachypnea/bradypnea? – we suspect r/t respiratory compromise, meds, anesthesia
- ______________ – we suspect r/t fluid bolus, Pitocin (anti-diuretic), magnesium sulfate

Answer

A

Unexpected/abnormal findings
- tachypnea – we suspect r/t fever or pain
- bradypnea – we suspect r/t respiratory compromise, meds, anesthesia
- fluid overload – we suspect r/t fluid bolus, Pitocin (anti-diuretic), magnesium sulfate

Question 8

Q

Postpartum physiological changes: Neurological

Expected or unexpected findings:
- Headaches – may be r/t fluid shifts in first week after birth, stress and fatigue?
- Headaches – may be r/t leakage of CSF from epidural (spinal headache, gets worse when you sit up)?
- Headaches – may be r/t chronic or gestational HTN?
- Headaches – may be r/t preeclampsia – can continue up to 6 weeks PP?
- Headaches with vision changes – spots, blurry, bright lights?

Answer

A

Neurological

Expected findings
- *Headaches – may be r/t fluid shifts in first week after birth, stress and fatigue

Unexpected/abnormal findings
- *Headaches – may be r/t
- leakage of CSF from epidural (spinal headache, gets worse when you sit up)
- chronic or gestational HTN
- preeclampsia – can continue up to 6 weeks PP
- Vision changes – spots, blurry, bright lights

Question 9

Q

Postpartum physiological changes: Nutrition

Expected findings
- May need to eat foods high in iron/fat? – r/t blood loss during labor
- May need to continue taking prenatal vitamins – especially if breastfeeding/suppressing lactation?
- Breast feeding mothers – increase/decrease calorie intake by 300 cal?
- Non-breastfeeding mothers – increase/decrease calorie intake by 200 cal?

Answer

A

Nutrition
Expected findings
- May need to eat foods high in iron – r/t blood loss during labor
- May need to continue taking prenatal vitamins – especially if breastfeeding
- Breast feeding mothers – increase calorie intake by 300 cal
- Non-breastfeeding mothers – decrease calorie intake by 200 cal

Question 10

Q

Postpartum physiological changes: Labs

Expected findings

Non-pathologic leukocytosis during first week post birth = WBC 25,000 – 30,000
If its higher than this suspect ________
Blood loss
Vaginal birth _____ mL
c/s birth ______ mL
losing 500 mL of blood = Hematocrit/Hemoglobin decline of 2-3%?
plasma levels go back to normal 4-6 weeks post birth
platelet levels go back to normal by the 6th week post birth
blood values go back to normal by the 6th week post birth

Answer

A

Labs
Expected findings
- Non-pathologic leukocytosis during first week post birth = WBC 25,000 – 30,000
- If its higher than this suspect infection

Blood loss
Vaginal birth 200-500 mL
c/s birth 700-1000 mL
losing 500 mL of blood = Hmt decline of 2-3%
plasma levels go back to normal 4-6 weeks post birth
platelet levels go back to normal by the 6th week post birth
blood values go back to normal by the 6th week post birth

Question 11

Q

Postpartum physiological changes:
Ovulation/menstruation

Expected findings for non-breastfeeding women or breastfeeding women?
- menstruation occurs in 7-12 weeks
- ovulation occurs by 70-75 days
- menstruation may be delayed by 3 months +

T/F
breastfeeding is not a reliable source of birth control

Answer

A

Ovulation/menstruation

Expected findings

non-breastfeeding women
- menstruation occurs in 7-12 weeks
- ovulation occurs by 70-75 days

breastfeeding women
- menstruation may be delayed by 3 months +

T - breastfeeding is not a reliable source of birth control

Question 12

Q

Postpartum physiological changes: Weight changes

Expected findings
-initial weight loss of 10-20 lbs – r/t baby/placenta/ amniotic fluid or postpartum diuresis?
-weight loss of 5 lbs – r/t baby/placenta/ amniotic fluid or postpartum diuresis?
-may return to pre-pregnant weight by 6-8 weeks postpartum – depends on person, diet, exercise, etc.

Answer

A

initial weight loss of 10-20 lbs – r/t baby, placenta, amniotic fluid
weight loss of 5 lbs – r/t postpartum diuresis
may return to pre-pregnant weight by 6-8 weeks postpartum – depends on person, diet, exercise, etc.

Question 13

Q

PP assessment - BUBBLEHE

which one?

breast - size and shape
nipples – cracks, fissures, soreness, inversion
breast fullness – r/t milk presence
abnormalities – reddened areas, engorgement
not breastfeeding = how to prevent engorgement, proper bottle feed info
breastfeed = assess how it is going, observe session, give praise and guidance, talk about prevent/treat engorgement/mastisitis/blocked ducts

Answer

A

Postpartum Assessment
B-Breasts

Question 14

Q

patients:
- non-lactating women
- breastfeeding mom
- women that doesn’t want to breastfeed
- women asking how to suppress lactation
- women with engorgement that is breastfeeding
- women with engorgement that isn’t breastfeeding

which of the above patients should the nurse advice do the following breast care:
- well-fitting bra or ace wrap binder
- cold compress or cabbage leaves
- anti-inflammatory meds
- avoid stimulating the breasts/nipples
- avoid warm water on breast in shower, shower with back to water
- avoid stimulating the nipple

Answer

A

non-lactating women
women that are not breastfeeding
need to suppress lactation
engorgement prevention/treatment for non-breastfeeding moms

Question 15

Q

lactation
- feed Q _____ hours (8-12 feedings/24 hours)
- feed _____ mins on 1st breast, offer 2nd breast but infant may not want it or feed as long on it
- expected/unexpected finding - breasts may feel heavy?
- expected/unexpected finding – breasts feel hardened, sore, reddened?
- breastfeeding women should only consume alcohol occasionally?
- don’t consume alcohol at least ___ hours before nursing?

Answer

A

feed Q 1.5-3 hours (8-12 feedings/24 hours)
feed 10-20 mins on 1st breast, offer 2nd breast but infant may not want it or feed as long on it
expected finding - breasts may feel heavy
unexpected finding – breasts feel hardened, sore, reddened
breastfeeding women should only consume alcohol occasionally
don’t consume alcohol at least 2 hours before nursing

Question 16

Q

breastfeeding positions
- _______ – both hands are around baby’s body
- ______________ – allows mom to have a free hand to manipulate breast
- _____________ – allows mom to have a free hand to manipulate breast and takes pressure off abdomen
- ___________ - allows mom to have a free hand to manipulate breast, risk of mom falling asleep and smothering baby

side-lying, cradle, football hold, modified cradle

Answer

A

breastfeeding positions
- cradle – both hands are around baby’s body
- modified cradle – allows mom to have a free hand to manipulate breast
- football hold – allows mom to have a free hand to manipulate breast and takes pressure off abdomen
- side-lying - allows mom to have a free hand to manipulate breast, risk of mom falling asleep and smothering baby

Question 17

Q

breastfeeding concerns and solutions

__________ – r/t poor latch, allow nipples to dry to prevent breakdown
____________ – teach privacy tactics
____________ – mom can pump milk, others can feed the baby, mom doesn’t have to be there
____________ - mom can pump milk and fathers can bottle feed, fathers can take responsibility for other tasks
______________ -
good signs to look for:
milk at edges of mouth
6-8 wet diapers/day
See Infant swallowing
Breasts softer after feeding

worried infant isn’t getting enough milk,
unequal responsibility or fathers feeling left out, embarrassment in public,
mom feeling tied down to demands of breastfeeding, nipple tenderness/pain

Answer

A

breastfeeding concerns
-nipple tenderness/pain – r/t poor latch, allow nipples to dry to prevent breakdown
-embarrassment in public – teach privacy tactics
-mom feeling tied down to demands of breastfeeding – mom can pump milk, others can feed the baby, mom doesn’t have to be there
-unequal responsibility or fathers feeling left out - mom can pump milk and fathers can bottle feed, fathers can take responsibility for other tasks
-worried infant isn’t getting enough milk
- good signs to look for:
- milk at edges of mouth
- 6-8 wet diapers/day
- See Infant swallowing
- Breasts softer after feeding

Question 18

Q

how does the nurse know the baby is getting enough milk? SATA
- milk at edges of mouth
- 3-4 wet diapers/day
- See Infant swallowing
- Breasts softer after feeding

Answer

A

milk at edges of mouth
X 6-8 wet diapers/day
See Infant swallowing
Breasts softer after feeding

Question 19

Q

Breastfeeding difficulties: Mom not producing enough milk

Mom increase fluid intake = ___ L/day

Answer

A

Mom increase fluid intake = 2 L/day

Question 20

Q

Breastfeeding difficulties: Sore nipples

Must have good latch = ______ shape mouth
Lanolin cream?
Express some breast milk and let dry on nipples?
Allow nipples to air dry?
Begin nursing on breast that is less/more sore?

Answer

A

Must have good latch = fish shape mouth
Lanolin cream
Express some breast milk and let dry on nipples
Allow nipples to air dry
Begin nursing on breast that is less sore – b/c baby will have stronger suck at the beginning of feed vs end of feed

Question 21

Q

Breastfeeding difficulties: Plugged ducts

Frequent nursing, changing feeding positions, manual massage, warm compress?
Start feeding on breast with plugged duct?
Breast pump may help dislodge plug?
Assess women for pressure from purse strap, infant sling, car seat belt, etc. that may cause _____________
Plugged ducts can lead to ______!!

Answer

A

Frequent nursing, changing feeding positions, manual massage, warm compress
Start feeding on breast with plugged duct – vigorous suck may help dislodge plug
Breast pump may help dislodge plug
Assess women for pressure from purse strap, infant sling, car seat belt, etc. that may cause recurring plugged ducts in the compressed area
Plugged ducts can lead to mastitis!!

Question 22

Q

Breastfeeding difficulties: Flat/inverted nipples

Rolling, stimulating?
Pump a little before breast feeding?
Use a nipple shield?

Answer

A

Rolling, stimulating
Pump a little before breast feeding
Use a nipple shield

Question 23

Q

Is this education for a weaning breastfeeding mom or a non-breastfeeding mom that is suppressing lactation?

Over a few days to a week - Substitute one cup of formula for one breastfeeding session (so breasts gradually produce less milk)
Over a period of several weeks – substitute more formula feedings for breastfeeding

Question 24

Q

Slow weaning is good b/c: SATA
- Prevents engorgement
- Allows infant to alter their own eating methods at their own rates
- Provides time for psychological adjustment
- mom can drink alcohol regularly

Answer

A

Prevents engorgement
Allows infant to alter their own eating methods at their own rates
Provides time for psychological adjustment

Question 25

Q

mastitis vs engorgement?

Question 26

Q

mastitis vs engorgement?

s/s
- sudden onset
- chills
- fever 101 F +
- malaise
- red, painful, swollen AREA on breast
- usually one breast affected
- discharge

Question 27

Q

mastitis vs engorgement?

treatment
- antibiotics (penicillin)
- warm compress
- analgesics

Question 28

Q

mastitis vs engorgement?

prevention
- wear supportive bra at all times (not constricting bra, underwire bra, restrictive clothing) = prevents milk stasis where bacteria can grow
- good handwashing, hygiene, air dry breasts
- prompt attention to blocked milk ducts
- regular complete emptying of the breasts
- good infant positioning
- good latch
- supply and demand – if baby feeds more/mom pumps more = body will cue to make more milk
- report flulike symptoms
- alternate breasts at feeding
- treat cracked nipples

Question 29

Q

mastitis vs engorgement?

s/s
- hard, painful breasts
- entire breast (not an area), or both breasts
- gradual onset
- NO fever

Question 30

Q

mastitis vs engorgement?

Treatment/prevention (for moms that are breastfeeding)
- Don’t miss a feeding
- Hand express or pump to soften breasts/nipples before feeding
- nurse 8-12x/24 hours and for 10-20 mins/breast each feeding
- warm compress before feedings – helps with let down before feeding
- cold compress between feedings – slows milk production
- well-fitted nursing bra 24/7
- cabbage leaves – help with edema
- breast feed more frequently – Q 1-1.5 hours

Answer

A

engorgement

Question 31

Q

engorgement treatment/prevention appropriate for moms that are breastfeeding or non-breastfeeding?

Don’t miss a feeding
Hand express or pump to soften breasts/nipples before feeding
nurse 8-12x/24 hours and for 10-20 mins/breast each feeding
warm compress before feedings – helps with let down before feeding
cold compress between feedings – slows milk production
well-fitted nursing bra 24/7
cabbage leaves – help with edema
breast feed more frequently – Q 1-1.5 hours

Answer

A

breastfeeding moms with engorgement

Question 32

Q

mastitis vs engorgement?

treatment/prevention (for non-breastfeeding moms)
- well-fitting bra or ace wrap binder
- cold compress or cabbage leaves
- anti-inflammatory meds
- avoid stimulating the breasts/nipples
- avoid warm water on breast in shower, shower with back to water
- avoid stimulating the nipple

Answer

A

engorgement

Question 33

Q

engorgement treatment/prevention appropriate for moms that are breastfeeding or non-breastfeeding?

well-fitting bra or ace wrap binder
cold compress or cabbage leaves
anti-inflammatory meds
avoid stimulating the breasts/nipples
avoid warm water on breast in shower, shower with back to water
avoid stimulating the nipple

Answer

A

non-breastfeeding moms with engorgement

Question 34

Q

postpartum assessment - BUBBLEHE

which one?

abdomen
uterine ligaments
striae (stretch marks)
after pains
diastasis recti abdominis

Answer

A

U-Uterus/Abdomen

Question 35

Q

postpartum assessment: U-Uterus/Abdomen

abdomen is loose and flabby?
abdomen will not respond to exercise?
uterine ligaments will quickly return to normal state?
striae (stretch marks) – different colors based on moms skin and time lapsed?
for c/s incision use REEDA scale when assessing?

Answer

A

abdomen is loose and flabby
X- will respond to exercise
X- uterine ligaments will slowly return to normal state
striae (stretch marks) – different colors based on moms skin and time lapsed
for c/s incision use REEDA scale when assessing

Question 36

Q

postpartum assessment: U-Uterus/Abdomen

after pains – intermittent uterine contractions r/t uterine involution/subinvolution?

the nurse should advice:
- rest prone/supine with pillow under abdomen?
- motrin for pain if platelets are less than 70,000?
- motrin for pain if has preeclampsia?
- motrin for pain if patient had multiples?

Answer

A

after pains – intermittent uterine contractions r/t uterine involution
rest prone with pillow under abdomen – helps keep uterus contracted
motrin – for cramping
contraindication – if platelets are less than 70,000, or pt has preeclampsia

Question 37

Q

postpartum assessment: U-Uterus/Abdomen

diastasis recti abdominis – separation of the ________ muscles

common in multiples or G1?
abdomen over distended?

Answer

A

diastasis recti abdominis – separation of the rectus (abdominal) muscles
common in multiples
abdomen over distended

Question 38

Q

postpartum assessment: U-Uterus/Abdomen

uterus
- should be undergoing involution or subinvolution?
- decrease/increase in weight 100 g?
- spongy layer – sloughed off?
- basal layer – splits into 2?
outer layer - sloughed off?
inner layer – foundation for new endometrium?
- placenta site heals by exfoliation?

Answer

A

uterus
- involution
- decrease in weight 100 g
- spongy layer – sloughed off
- basal layer – splits into 2
- outer layer - sloughed off
- inner layer – foundation for new endometrium
- placenta site heals by exfoliation

Question 39

Q

postpartum uterine infection: Endometritis
infection that involves the lining of the uterus

s/s
- uterine tenderness
- temp spike 104 F
- chills
- foul smelling lochia or vaginal discharge

Question 40

Q

infection that involves the lining of the uterus

Answer

A

Endometritis

Question 41

Q

mastitis or endometritis?

s/s
- uterine tenderness
- temp spike 104 F
- chills
- foul smelling lochia or vaginal discharge

Answer

A

Endometritis

Question 42

Q

risks for developing mastitis or endometritis?
- c/s delivery
- PPROM
- Prolonged labor
- Multiple vaginal exams during labor, especially after ROM
- Use of FSE or IUPC
- Instrument assisted deliveries – vacuum or forceps
- Manual removal of placenta
- Chorioamnionitis – infection of chorion and amnion

Answer

A

postpartum uterine infection: Endometritis

Question 43

Q

Treatment for mastitis or endometritis?
- Antibiotics – clindamycin, gentamycin
- Culture and sensitivity (will show specific antibiotic that works on this infection)
- Continue treatment until afebrile for 24-48 hours

Answer

A

postpartum uterine infection: Endometritis

Question 44

Q

postpartum assessment: U-Uterus/Abdomen

Fundal assessment determines:
- position of fundus r/t __________ - above or below
- position of fundus r/t __________ - left, right, centered
- uterus tone - _______ or ________

Answer

A

Fundal assessment
Determines:
- position of fundus r/t umbilicus - above or below?
- position of fundus r/t midline - midline or offcentered?
- uterus tone - firm or boggy?

Question 45

Q

postpartum assessment: U-Uterus/Abdomen

Fundal assessment

uterus should be at level of umbilicus for 6-12 or 12-24 hours post birth?
uterus contracts 1 or 2 fingerbreadth per day (involution)?
uterus descends 1 or 2 cm/day towards pelvis, until it is in the pelvis on the 10th day?

Answer

A

uterus should be at level of umbilicus for 6-12 hours post birth
uterus contracts 1 fingerbreadth per day (involution)
uterus descends 1 cm/day towards pelvis, until it is in the pelvis on the 10th day

Question 46

Q

postpartum assessment: U-Uterus/Abdomen

Fundal assessment

place one hand below umbilicus and other hand on symphysis, apply downward pressure toward vagina = determines if _______ is firm and assists client in expelling ________

Answer

A

place one hand below umbilicus and other hand on symphysis, apply downward pressure toward vagina = determines if fundus is firm and assists client in expelling clots

Question 47

Q

postpartum assessment: U-Uterus/Abdomen

expected or unexpected findings in fundal assessment? If unexpected, what do we suspect?

uterus should be at level of umbilicus for 6-12 hours post birth
uterus contracts 1 fingerbreadth per day (involution)
uterus descends 1 cm/day towards pelvis, until it is in the pelvis on the 10th day
uterus is off to one side (or is high in the abdomen)
uterus did not change in size from yesterday to today
uterus did not make descending progress towards pelvis
uterus is firm
uterus is soft
uterus is midline

Answer

A

E - uterus should be at level of umbilicus for 6-12 hours post birth
E - uterus contracts 1 fingerbreadth per day (involution)
E - uterus descends 1 cm/day towards pelvis, until it is in the pelvis on the 10th day
U - uterus is off to one side (or is high in the abdomen) = pt needs to void (empty bladder)
U - uterus did not change in size from yesterday to today = subinvolution, suspect retained placenta fragments and infection
U - uterus did not make descending progress towards pelvis = subinvolution, suspect retained placenta fragments and infection
E - uterus is firm
U - uterus is soft = indicates uterine atony and increased bleeding, nurse should perform fundal massage
E - uterus is midline

Question 48

Q

causes of boggy uterus/fundus? SATA
- high levels of oxytocin
- multipara
- small for gestational age
- multiples
- LGA - Large for Gestational Age
- Red haired women
- trapped gas

Answer

A

high levels of oxytocin = uterus no longer responding to meds that promote contraction of uterus
multipara
X- small for gestational age
multiples
LGA - Large for Gestational Age
Red haired women
X- trapped gas

Question 49

Q

Documenting the fundal assessment

FF u/-2 =

UU =

Answer

A

FF u/-2
- Firm Fundus = FF
- 2 fingerbreadths below umbilicus u/-2

UU
- At level of the umbilicus

Question 50

Q

postpartum assessment - BUBBLEHE

which one considers bowel movements?

Answer

A

B - bowels

Question 51

Q

postpartum assessment: Bowels

Bowels will be sluggish r/t: SATA
- Progesterone
- increased muscle tone
- Birth process
- Anesthesia

T/F - Women should expect to have her first BM up to 3 days after delivery

Answer

A

Bowels will be sluggish r/t
- Progesterone
X - Decreased muscle tone
- Birth process
- Anesthesia

T - Women should expect to have her first BM up to 3 days after delivery

Question 52

Q

postpartum assessment: bowels

T/F

Episiotomy, lacerations, or hemorrhoids may speed up elimination/BM after birth?

Might moms have a fear tearing with BM?

would appropriate treatment include stool softeners for moms with Episiotomy, lacerations, or hemorrhoids ?

Are tucks pads appropriate to use for hemorrhoid itching and coolness?

does knee pain often indicate trapped gas?

Answer

A

F - Episiotomy, lacerations, or hemorrhoids may delay elimination
T - Mom may fear tearing
T - Treatment – stool softeners
T - Tucks pads for hemorrhoid itching and coolness
F - Shoulder pain = trapped gas (often right shoulder pain)

Question 53

Q

postpartum assessment - BUBBLEHE

which one considers
- bladder capacity
- urethra
- urinary output
- sensation and sensitivity
- infection

Answer

A

B - bladder

Question 54

Q

postpartum assessment: B-Bladder

Increased/decreased bladder capacity during pregnancy?
Swelling and bruising of tissues around urethra?
Increase/decrease in sensitivity to fluid pressure?
Increase/decrease in sensation of bladder filling (esp. w/ epidurals)?
Urinary output is higher/lower due to diuresis?
Increased/decreased chance of infection due to dilated ureters and renal pelvis?
Monitor adequacy of urinary elimination and distention?

Answer

A

B-Bladder
- Increased bladder capacity during pregnancy
- Swelling and bruising of tissues around urethra
- Decrease in sensitivity to fluid pressure
- Decrease in sensation of bladder filling (esp. w/ epidurals)
- Urinary output is greater due to diuresis – kidneys rid 2000-3000 mL of extracellular fluid
- Increased chance of infection due to dilated ureters and renal pelvis
- Monitor adequacy of urinary elimination/distention

Question 55

Q

what type of infection should the nurse suspect with these s/s
- Frequency and urgency
- Dysuria
- Nocturia
- Hematuria
- Suprapubic pain
- Slightly elevated temp

Question 56

Q

postpartum assessment - BUBBLEHE

After delivery, vaginal discharge of blood, mucus, atrophied uterine cells/debris

Answer

A

L - Lochia

Question 57

Q

postpartum assessment: Lochia

_______ days = lochia rubra (red)
______ days = lochia serosa (pink)
_______ days (until cervix is closed) = lochia alba (white)

Answer

A

2-4 days = lochia rubra (red)
4-10 days = lochia serosa (pink)
10-20 days (until cervix is closed) = lochia alba (white)

Question 58

Q

postpartum assessment: Lochia

-2-4 days = lochia rubra= color ________
-4-10 days = lochia serosa = color _______
-10-20 days (until cervix is closed) = lochia alba = color __________

Answer

A

2-4 days = lochia rubra (red)
4-10 days = lochia serosa (pink)
10-20 days (until cervix is closed) = lochia alba (white)

Question 59

Q

The nurse is doing a fundal assessment on a postpartum patient. The nurse notes bleeding that saturates the peripad in 1 hour and a soft fundus.

What does the nurse suspect?

What should the nurse do?

Answer

A

saturated bleeding + boggy fundus = Uterine atony

perform fundal massage

Question 60

Q

The nurse is doing a fundal assessment on a postpartum patient. The nurse notes bleeding that saturates the peripad in 1 hour and a firm fundus.

What does the nurse suspect?

Should the nurse do a fundal massage?

Answer

A

saturated bleeding + firm fundus = Lacerations

fundal massage is not helpful, nurse should assess the perineum, REEDA

Question 61

Q

T/F - Weeks 5-6 uterus will return to normal size

Question 62

Q

postpartum assessment: Lochia

Amount
- Scant
- Light
- Moderate
- Heavy = saturated peripad within __ hour(s). This is too much bleeding = _________________

Answer

A

Heavy = saturated peripad within 1 hour. This is too much bleeding = postpartum hemorrhage

Question 63

Q

-Uterine atony
-Lacerations
-Episiotomy
-Retained placenta fragments
-Hematomas
-Uterine inversion – prolapse of uterus
-Uterine rupture
-Placenta implantation problems (accrete, increta, percreta)
-Coagulation disorders – low platelets, DIC

these are all complications that can cause ________________ in a postpartum woman

Answer

A

Postpartum hemorrhage

Question 64

Q

s/s of postpartum hemorrhage include: SATA

Excessive bleed, heavy bleed
dark red bleed
Boggy fundus that doesn’t respond to massage
Abnormal clots

Answer

A

Excessive bleed, heavy
X- Bright red bleed
Boggy fundus that doesn’t respond to massage
Abnormal clots

Answer 56

A

High temp
Pelvis discomfort or backache
Persistent bleed + firm uterus
X - Fundus rises in abdomen

Answer 57

A

X- Increased pulse
- Decreased BP
- Decreased LOC
- Hematoma formation or bulging/shiny skin in the perineal area

Answer 58

A

Uterine massage (for soft uterus)
Assess perineum for bleeding or clots
Frequent void or cath the woman
Look for abnormal Hct levels – CBC repeated on 1st day postpartum
X - Diet high in iron

Answer 59

A

X- Magnesium Sulfate
- oxytocin
- Methylergonovine maleate (methergine)
- Carboprost
-Misoprostol (Cytotec)

Answer 60

A

-Oxytocin – after delivery of placenta and early postpartum period
-Methylergonovine maleate (methergine) – don’t give to woman with HTN b/c of rebound HTN risk
-Carboprost – s/e diarrhea
-Misoprostol (Cytotec) – route: rectal, followed by oral (may be given vaginally before birth)

Answer 61

A

E-Episiotomy/Lacerations/Incision

Answer 62

A

1st - Involves only the skin around the vaginal opening
2nd - Involves the skin and underlying muscles, requires stitching, most common
3rd - Involves the skin, muscles, and anal sphincter
4th - Involves the skin, muscles, anal sphincter, and rectal lining.

Answer 63

A

REEDA scale

R = redness
E = edema of swelling
E = ecchymosis or bruising
D = discharge
A = approximation – how well the edges of the laceration seem to be holding together

Answer 64

A

R = redness
E = edema of swelling
E = ecchymosis or bruising
D = discharge
A = approximation – how well the edges of the laceration seem to be holding together

Answer 65

A

Interventions for Episiotomy/Lacerations/Incision

Answer 66

A

-Minimize respiratory complications
X-resume any activity level
-Deep breathing
-Incentive spirometry
-Ambulation
-Rest between infant care and self care
-Pain management - OTC med
-Minimize gas pains
-Mylicon - OTC gas med
X- bedrest

Answer 67

A

-side lying with superior leg elevated

Answer 68

A

H-Homan’s/Hemorrhoids

Answer 69

A

hemorrhoid care

Answer 70

A

pt c/o pain when walking
redness in calf
warmth in calf
X - homan’s positive sign

Answer 71

A

pain in leg
pain in inguinal area
pain in lower abdomen
one sided edema in leg

Answer 72

A

temperature changes in extremity
pain when the nurse palpates leg
X- one sided itchiness in leg

Answer 73

A

-Avoid prolonged sitting
-Avoid prolonged standing
-Avoid crossing legs
-Take frequent breaks while traveling by car, plane, etc.
-SCDS
-Early ambulation
X-Adequate fluid intake

Answer 74

A

E-Emotions/Psychological

Answer 75

A

“taking in” phase
- 1-2 days after birth
- Passive, dependent
- Processes reality vs imagined birth experience
- Food and rest are important

“Taking hold” phase
- 2-3 days after birth
- Control, mothering
- Continue to provide assurance and support

Answer 76

A

Becoming a mother (BAM)
- Anticipatory stage – during pregnancy - role play, expectations
- Formal stage – birth – role guided by expectations of others in her social system
- Informal stage – develops role individually
- Personal stage – self, confidence, and competence as mother role

Answer 77

A

PP depression

Answer 78

A

PP depression

Answer 79

A

PP psychosis

Answer 80

A

Nursing care: PP blues, PP depression, PP psychosis

Answer 81

A

1st line = sertraline
2nd line = parozetine

-Prozac not recommended with breastfeeding moms

Answer 82

A

PP psychosis

Answer 83

A

Enface (maternal response) – direct eye contact, face to face
Engrossment (paternal response) – absorption, interest, preoccupation

Answer 84

A

-Rest
-Resume normal activities
-Avoid heavy lifting
-Avoid climbing stairs multiple times a day
X-Avoid strenuous activity

Answer 85

A

X - Resume after lacerations healed and lochia stopped – about 4-6 weeks
- Lubrication
- Contraception

Answer 86

A

Stable vitals
Involution of uterus
X - Lochia amount must be ok (scant, light, moderate) + no sign of infection
Education s/s of infection
Lacerations well approximated

Answer 87

A

Ability to perform pericare and meds as ordered
Ability to void and pass gas
X - must have ability to take fluids and foods without difficulty
Ability to identify s/s PP depression and resources
Reviews teaching material and shows how to care for self and baby

Answer 88

A

X- must show Appropriate interaction with baby such as not leaving the baby unattended and correct feeding practices
- Practices principles of infant safety
- Rubella (MMR injection) – if non immune
- RhoGAM injection – if neg mom, pos baby, or direct combs neg

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