Madenal Chill - Test #3 (Ch 6, 9, 12, 13, 15, 21, 22)
Spedaity Nursing Pily 1728
1 what is the possible sitle efflects for a neonarte in
Preterm pregnancy fetal lungs not reaby, greatest rok is to tihe flettus
h Prolonged or post-term pregnancy disk of placental insufficiency, fetal wt loss, vealling suiy,
4-02/nutrients, passage of mecorium, hypogfycenia
what is the difference in characteristics between the
Pretienmc skin transparent and loosers
fat; lanugo present; vernix caseosa is:
and postenm newhome
veins may be seen in sbdomen and scaigg lach of 90
extremities short: sole of feet have flew creases;
abdomen protrudes; nails are short genita Ta are small, and baba majora may beagen
lost, stin loose, esp around thighs and buttocs;
Postitennc long and thing looks like weight has b
be
stained w/mecsniumg tlick head of italing lo
lanugo or vernix caseoszr; neils longs and
allert
Location felt at the level of
preadth fwitith) per day (by day 10;
slightly lower or above; descends about 1om fingess
not be able to pallpate oterus)
lone hand
Consistency: firm mass, size of a g
in circuler
above, one below (prevents inverting
Afterpains: intermittent uterine contraction
ar to menstrual cramping; cam ocour more
w/breastfeeding due to release of oxytocin (causes uterine contractions) decreases rapidly o fin
48hrs after birth
How dioes massaging a boggy uterus control uterine bleeding? When should massaging be completed? Hiow
should the fundus be massaged?
2. Causes uterine muscles to contract which sealls off blood
vessels where placenta was attached to
uterus;
b. Massage anytime the uterus is boggy (soft, relaxed)
over the fundus and one below the uterus (to prevent turning inside/out) and rub the
fundus in a circular motion with slight pressure until firmness returns
Place one hand
What should be reported? Pad use?
and describe the 3 stages of lochia, including the duration of each.
a. Lochia rubra-red discharge made of mostly blood; birth to 3 days post
b. Lochia serosa-pinkish brown
C.
d.
discharge from blood and mucus content; 3-10 days post
Locia alba-creamy white, clear, colorless discharge made of mostly mucus; 10-21
days
#Lochia should have a fleshy or menstrual odor
e. #Lochia should
be
monitored frequently; if excessive discharge noted, check fundus (should be firm
pads can be counted or weighed to
and miline), provide a clean pad and recheck w/in 15 minutes;
determine accurate output; assess underpads as well to determine extent of discharge; pooling occurs
in
the mother while laying down and lochia will be heavier once standing ("gush"); small clots are
expected NOT
large ones; women w/cesareans may produce less lochia w/in 1 24 hours; apply
pads
front to back
*Report foul smelling lochia, return to previous lochia stage; excessive clots; bright red trickle or
spurting
4.
The new mother can expect her menstrual periods to resume in-
return
Whereas, in the breastfeeding mother,
_weeks if she is not breastfeeding.
of ovulation and menstration are around 8 weeks
U
What should be assessed on the mother postpartum?
a. BUBBLE:
b.
Breast appearance, lactation, full but soft 1# 2-3 days; Uterus fundal location, size, and condition;
Bowel sounds monitored for return and presence, monitor for constipation; Bladder monitored for
bladder size, and/or anesthesia, encourage voiding q 2-3 hrs;
Lochia is shedding of uterine lining, monitor amt, color, odor, clots, pad use; Episiotomy/Laceration/
voiding for @ least the 1 2-3 voids, V
section Incision monitored for infection, dehisence, eviseration, approximation, suture/staple amt,
drainage, hematoma, ecchymosis, hemorrhage
Describe colostrum and the benefits of colostrum for the neonate.
Yellowish fluid rich in antibodies, protein, vitamins A and E, minerals, nitrogen, calories; "early milk" for the
2-3
1
days; contains a natural laxative to help w/ passage of meconium
Describe the
appropriate nursing teaching in the following areas for postpartum discharge:
Hygeine: daily baths/showers encouraged while lochia present; perineal care to be taught (i.e. apply
front to back, etc.) and completed with warm water from front to back w/each voiding
(BM/urination) especially while episiomy or laceration repair present/healing
b.
C.
Sexual intercourse: safe to resume intercourse when bleeding has stopped and perineum is healed
Diet: breastfeeding mothers to ^ caloric intake by about 500 calories; well balanced; be aware of
cultural influences (esp. during hospitalization; ex. Some cultures have their own dietary choices to
help healing, provide luck, etc. after pregnancy) and as long as it doesn't cause harm, try to respect
and aide the patient
Cord care: clamp will be removed before leaving hospital; cord will shrink, discolor, and fall off w/in
10-14 days after delivery (contact PCP if this does not happen); cleaning cord and under circumfirence
of cord w/ warm water or ETOH pads w/q void (BM/urination); may instruct to apply triple dry,
betadine, or abx cream to promote drying of cord; leave open to air; do NOT pull on
report foul odor, drainage, or redness
e.
cord or pull it off;
Lactation suppression: wear a snug bra 24h/d, do NOT stimulate nipples (stand w/back to shower
directly on breasts, loose clothes), ice packs, analgesics, breasts return to
spray, no warm water
normal size in 1-2 weeks, report hard, erect,
very
breasts do not return to normal size
20. What
are the average head circumference,
uncomfortable breasts (engorgement) especially if
weight, and length for the newborn?
a. Head: 32-36 cm
b.
C.
Weight: 6-9 Ib
Length: 19-21.5 in
n. List 2 functions
of an infant's fotanels.
a. Allows for molding of head during delivery
b.
Allows for brain growth
C.
Unossified spaces; "soft spots"; anterior (diamond shaped-closes by 18 months) and posterior
F
(triangle shaped-closes in 8-12 wks)
d.
-
Bulging=^ ICP; sunken=dehydration
•
2.) Describe APGAR scoring, when it is assessed, and what each rating indicates.
a. 5 factors are used to
¥
b.
HR:
determine infant's condition and response ot resuscitation.
0-2 pts; 110-160; none, less than 100, over 100
Resp. effort: 0-2 pts; 30-60,
crying effort-none, slow/irregular, good
•
HR
Resp
muscle tone
•
reflex
response
•
•
skin color
3¥43
Muscle
e. Reflex
f.
Skin
g.
tone: 0-2 pts; flexion of
responses
color: 0-2
8-10-good
3-severly
contd observation/suppornt
depressed(needs resusciardi 4-1-moderatelydepressed(gentle stimulation/backrub);o.
:)What are s/s of cold
b.
stress? What interventions
+. What signs would indicate
lead
mottling of
skin(purplish color),lethargy
warmer, wrappingin blanket, skin to skin
to hypoglycemia/respiratorydistress; conserva heat first after birth
lack of bonding on
the mother's part?
when baby cries;disgust
Apathy
or doesn't
What is
cold stress?
Coaning
newborn immediately, cab of head, radiant
covered with blanket
greatest riskto newborn-can
15.
arms/legs; limp, some,
Rets artiracet a,
conl simulnion
pts;paction
pale, pinkorw/blue
extremities, pink
pts; none, grimace, cry
when
baby voids,stools, or spits up;
disappointment
men
mancto holdi tunores or deesrtallthou2t aisiuetdhamnott
in
newborn; turns away
pathological jaundice and physiological jaundice?
a. Due to immaturity of
newborns liver, the liver is unable to
of postnatal breakdown
b. The higher the
because
clear the blood of bile pigments that occur
bilirubin the deeper the jaundice and greaterrisk
--_-_
=iÉn
C.
nystological-normal; typicallyifseen, will be
for
neurologic damage
16. When does physiologic jaundice appear?
a.
2-3 days after birth
lastsabout week; neverseenw/in 24hrs blimth
calledicterus neonatorum;
occurs from
rapid destruction of excess RBCs by the immature liver
causing a yellow tinge to infant's skin
b. Also
and
1*
1
of
List 8 advantages of breast feeding. Disadvantages.
€
• does hta ear seontain full ranse of nutrients the infant needs in correct proportions, ebsly dieestad
allergies, natural immunity transfer of antibodies, laxative effect, suckling prorsted;
mouth development, fewer ear infections, promotes
weight loss, etc.
b.
Disadvantages: potential for most medication to enter breast
milk, requires work/commitment, true
galactosemia is contraindicated, women who abuse
drugs/alcoho should
have untreated active TB, HIV, Hep. B or C, or CA should not breastfeed not breastfeed, women who
.
_
(f18/What breast feeding interventions would need
a.
return of uterus to prepregnant state, maternal
_
to
_
.
-
included in patient teaching and care?
Wash hands before breastfeeding; clean breasts
w/warm
session; mom needs to be comfortable for feeding;
water, NO soap especially after each
manually express colostrum to make nipple erect;
infant's mouth should cover entire areola; nurse for AT LEAST 10 minute but nurse
long enough for
infant to get "hind milk"
especially before changing breasts; apply safety pin to bra above the last
breast used to remind mom to begin with that breast in
the next session (this allows alternating
of
breasts); feeding should NOT hurt; feeding sessions should be q 2-3 hrs (keeps
them on a schedule; so
they are not starving
when they wake); burp infant when swapping breasts and after session; wear
breast pads for leaking and change when wet; supportive bra worn 24 hr/day; use C hold
to place
nipple/areola into mouth; break suction by putting a finger into the side of the cheek to
break suction;
elicit rooting reflex to encourage nipple latching; know hunger signs
(19. )What signs would indicate
Rfr?%
the neonate is
experiencing respiratory distress? What can
cardiopulmonary function in newborns?
Persistant cyanosis (other than acrocyanosis); grunting
be done
to maintain
respirations (noise heard w/o stethescope);
nostril flaring, sternal and intercostal retractions; sustained RR > 60 per minute; sustained HR > 160 or
=
< 110
remove mucus and
b. ***Maintain cardiorespiratory function by wiping the face, nose, and mouth to
bulb
to
suction
mouth/nose
(spontaneous
excess amniotic fluid (held dependent-gravity); use
color at birth
after
stabilized;
cord
clamp
applied
breathing begins w/in a few seconds after birth);
QUICKLY turns pink; acrocyanosis is normal; 02 may be administered until infant
may be cyanotic but
crying vigorously
What is included in neutral thermoregulation of newborn?
a.
Because a newborn is less efficient at maintaining body heat, hypothermia (low body temp) can
problems for the infant (hypoglycemia and respiratory
cause
distress)
b. Neutral thermoregulation:
hat on the infant's head (biggest
Drying the infant; placing the infant in radiant warmer; placing
room (body
the infant after becoming stable; warmed blankets; warm
source of heat loss); wrapping
temp is influenced by
temp of room and blanket, essentially its environment)
What 3 medications are normally administered to
the
newborn? Why?
silver nitrate (prevents infant from getting opthalmia neonatorum (neonatal
in both eyes w/in 1st
conjunctivitis) that is caused by gonorrhea and chlamydia; given as ointment
.
a. Erythromycin or
hour of birth)
b.
C.
Vitamin K (assists in blood clotting bc infants intestinal flora that produces vitamin K is not present in
lateralis)
=
newborns;
Hepatitis vaccination (recommended for all
given IM to vastus
newborns; DO NOT give in the same thigh as vit. K;
B
parents Hep B + - newborn will get immunoglobulin and 1st vaccine w/ in 12 hrs of birth then @ 1
month, 2 months, an d 12 months)
be observed/documented before
What 2 elimination activities of the newborn have to
be
discharge? What should
reported?
a.
b.
C.
Urination and meconium (1St stool) passage
May not urinate for up to 24hrs/ meconium may be passed w/in
If
passage occurs in the LDR-DOCUMENT
8-24hr after birt
voiding/meconium
d. CanNOT be discharged home until BOTH have been observed.
if voiding/meconium passage has not occurred w/ in 24 hrs after birth
e. Report
23. What is caput succedaneum?
a.
Swelling (edema) of soft tissues of the scalp; crosses the suture lines; caused by pressure of the
presenting part against the cervix; will subside w/ o tx in 3-4
days
24. What is cephalohematoma?
a. A collection of blood btwn the periosteum (dense layer of vascular connective tissue) and the cranial
bone; can affect one or both sides; does NOT cross the suture line; caused from trauma during
delivery; will subside w/o tx in 2-3 wks
. What are the newborn transition phases? What occurs in each?
a.
Phase 1: 0-30 minutes; period of reactivity; tachycardia, irregular respiration, rales present
w/ auscultation, alert, frequent Moro reflex, tremors, crying, ^ motor activity
b.
Phase 2: 30 min - 2hrs; decreased responsiveness; I motor activity, rapid respirations (up to60 per
minute), normal HR, audible bowel sounds
=
C.
Phase 3: 2-8hrs; second period of reactivity; abrupt brief changes in color and muscle tone, presence
of oral mucus
(may cause gagging), responsiveness to external stimuli, infant stabilizes, begins
-
suck/swallow coordination and ready for regular feedings
_
26. What 2 hearing tests are used to test newborn hearing?
infant's ear and brain responds w/ a specific brainwave
b. OAE: (otoacoustic emission); measures sound from the cochlea in response to sound stimulation
a. ALOG: uses series of soft clicks in sleeping
27. When do tears appear?
Saliva?
a. Tears are absent at birth; appear
b.
w/crying- 1-3 months of age (Lacrimal ducts are immature)
Saliva- 2-3 months (salivary glands do not secrete saliva immediately after birth)
28. How often should the mother be
monitored for urination after delivery? What interventions can be used to
with voiding? When is MD notified?
a. Regularly assist woman's bladder for distention after delivery; may not feel full to woman but uterus
assist
appears high and deviated from midline; monitor output for the 1st 2-3 voids after delivery; f/c and/or
-
IVFs-monitor output until discontinued then the 1st 2-3 voids (mainly for f/c removal)
b. Massage fundus until firm, assist woman to restroom (can provide privacy, not rush, cut on running
water, run warm water over hands while on toilet, or use peribottle to squirt warm water on
perineum to relax urethral sphincter), then once voided and measured, reassess fundus (massage if
_
needed); initial discomfort is normal but not a consistent buring or discomfort w/urination
What postpartum blues? Postpartum depression? What would nurses need to
do to
encourage expression of
feelings?
a.
Postpartum blues-may feel let down but overall finds pleasure in life, self-limiting; for 14 few weeks
after birth
b.
Postpartum depression-persistent mood of unhappiness, not finding pleasure in life (lack of
enjoyment, disinterest in others, feelings of guilt or adequacy, disturbed sleep/appetite patterns,
constant fatigue, etc.); usually occurs 2-4 wks after birth; report to MD
What would be included in newborn assessment and care?
APGAR scoring at
initially 1 and 5 minutes; thermoregulation; maintaining cardiorspirtor function; infant
identification (ID bands, prints, photo, alarm); observe for passage of
meconium/void and record/document;
assess for major anomalies/injuries, symmetrical movement, reflexes (Moro, tonic neck, etc), fingers/toes,
gestational age (Ballard scale), obtain V/S, murmurs, genitalia abnormalities, skin; encourage
It
breastfeeding/bonding medication administration; measurements (head, chest, length, weight)
31. What is a common visual issue in
newborns?
Strabismus; normal; should correct itself
a.
.)How would the nurse determine hypoglycemia in the newborn? How is glucose level determined?
s/S: jitteriness, irritability, poor muscle tone, sweating, respiratory difficulty, . temperature, poor
a.
suck, high pitched weak cry, lethargy, seizures (brain is totally dependent on glucose for metabolism
in newborns)
b.
→
Lateral aspect heel stick is used to determine glucose level; < 45 mg/dl is considered hypoglycemia;
those at risk (pre-term/post-term infants, gestational DM or DM mothers, infants w/cold stress, etc.)
are checked w/in
hr after birth and at
intervals until glucose is stable
what order?
33. What V/S results should be expected in a normal term newborn? Collect V/S in
minute
x1
nose
breathing;
seconds,
RR: 30-60; periods of apnea < 15
a.
b.
HR: 110-160; apical pulse x 1 minute
C.
Temperature: 97.6-99.6; not rectally
d. B/P: 65-95/30-60 mm/hg
6%60--951680
e. Pain:
NIPS, PIPPS, Wong
Baker, etc.-determined by observation of expressions, posturing, and sounds
(behavior)
(RR, HR, Temp, then B/P-so the results will not be altered from pt
getting upset)
f.
(94) What instructions would the nurse given parents regarding bottle feeding?
Formula kind (ready to feed
(no dilution), concenrated,
a.
Gavage?
powder), may use tap water (if questionable,
boil or use nursery water), do not store after using (bacteria growth), no cow's milk until after 1 year,
can use warmed milk or from refrigerator (infant preference), always test formula first, do NOT use
microwave for warming (hot spots), no propping bottle for feeding, bottle tip is filled with formula to
prevent excess air being swallowed during entire feeding,
burp every oz or fewer if needed to
prevent regurgitation
Gavage-feeding tube by way of nose or mouth to stomach; infants are nose breathers so the mouth is
preferred for tube placement; administration of feeding the same as NG tube-CHECK PLACEMENT
(aspirate stomach contents or small amt of air) before flush (before and after w/sterile H2O), elevate
head (prevent aspiration) and leave up for at least 30 min after feeding, pacifier can be given during
feeding to satisfy hunger, flow in by gravity (never push)
b.
35. What
should nurses do in regards to medication dosage and why?
CAlways get a second nurse to check dosage; pediatrics are more susceptible to effects of medications than
adults
36. Why
would nurses involve parents in care of the child during
a.
hospitalization?
The concept of partnership w/parents is 1 parental involvement in patient care; treated as equals in
deciding what is important for themselves and their family; parents of special needs children often
become the expert in their child's condition; parents who are involved in
care have a sense of
contribution to the child's recovery; essential to
establish an effective working relationship w/ parents
asap; parents are the most significant individuals to a child and they know the child better than
anyone else; as the parent's comfort level ^ they become more involved in
meeting their child's
physical needs
37. Explain the pediatric procedures completed during hospitalization.
a.
Bathing-provides opportunity for assessment; check water temp; use dry hands to pick up infant;
never leave
unattended; don't get umbilical cord soaked if still present and clean around it w/alcohol
or warm water
Feeding-see earlier question (34)
C.
Urine collection-obtaining specimen for testing; methods include: suprapubic bladder tap, plastic
catheterization
Intake and Output-need accurate 1/0 monitoring; all fluids given to the child are documented; can
urine collection bag (u-bag),
have
parent assist w/form @ bedside; all urine voided is documented also(weigh diapers if
warranted)
e. Venipuncture-used to obtain blood specimens; infants and young children may have the jugular or
femoral vein accessed for sample; other sites include arm and hands; hold pt
securely; apply pressure
post procedure
f.
Lumbar puncture-used to obtain cerebral spinal fluid specimen; empty bladder pre-op; explain
procedure to parent/child (frightening); EMLA cream
may be used (apply to lumbar area); position
child on side @
edge of exam bed facing the
nurse
nurse should hold pt securely until completed;
post-procedure, pt can play quietly and move freely;
monitor for bleeding, hematoma, infection,
and signs of difficulty
Suctioning-used when audible secretions are heard in airway or signs of airway obstruction or oxygen
deficit are present (restlessness, anxiety, ^RR, 1HR, 1 temp, dyspnea, drooling, rattling, etc.);
nurse to
g.
w/neck and legs gently flexed (knees to chest);
•
h.
suction-depth ¼ to ½
oral yanker); for ET/Trach tube
to longerthan 5 seconds allowing 30sec btwn attempts®
carefully
oxygen in blood; monitor
trebuieyoue todevelopment of oxygen toxicity (monitor02 sats, ABGs,of LOC
(progress to
Incubator-closed/sealed container,
ili.
has vents
that
performed,maintain constant temp
need to
opened before procedures are
anascontinuous
went
secretions, cally obwerved through tent, has to he tuched/incured
iliuetyingcompressed
well,tent
provides
02that runsthrough sterile water(mist), makes for a
cooland moist environment, check temp
and
linens frequently (if wet, change linens and
gown)
iv.
wasal cannula-provides 02 continuously, use per order, problematic due to random head
movements, monitor carefully
Tracheostomy-02 mask made specifically for trachs, resembles a small face mask by cover the
trach opening providing a prescribed flow of 02
urn infant
----_
Vocabulary:
Acrocranosis_ Perviphera\ bluwass of the
Puerperium
Scarf sign
Bonding
- Amochnant; partrh- nwboin
Moro reflex ( Stoxgie RaPiox)
Involution-hollino or turning inward
Fundus - Up pex portion of ulexus bit
Epstein's pearls
Surfactant - Conbilules to the
nands and leet due to Vedu ced
Milia
Tonic neck reflex
Colostrum - Phre- milk,contains nanwal larative
Makarnal dlischarget blond, mucus thosu
Icterus
-expansion
Jaundico
of the
• Milia - Vavy small, whik , buxo-in-Gilel
Usually disapp2ov WAh
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49. What are some preterm
labor medications and interventions? Interactions?
It
a. Medical tx-bedrest and hydration for mother; tocolytic drugs (indomethacin (Indocin), nifedipine
(Procardia), magnesium sulfate (drug of choice but monitor for Mag toxicity (antidote=calcium
gluconate)), terbutaune) to suppress contractions, and steroids (betamethasone, dexamethasone) to
mature fetal lungs (given IV)
b. Interventions: monitor mother's pulmonary function, FHTs, dly wts, restrict oral and IVFs (L risk of
pulmonary edema); report maternal HR 140, persistent ^ of pulse rate, irregular pulse, 1 RR > 20
50. What is uterine
atony and how is it treated?
Lack of normal uterine muscle tone causing the blood vessels at the placental site to
a.
usually massively
bleed freely and
E-÷__
b. s/s: uterus is hard to feel, boggy, fundal
height is high, lochia is increased/may contain clots
c. bladder may be full and to one side (assess fundus, massage, assist w/urination, reassess fundus)
d. massage until firm, can
express clots once uterus is firm; if massaging does not work-pitocin can be
initiated, per MD order; extreme cases may need hysterectomy; do NOT leave alone
51. What can contribute to postpartum
hemorrhage and how its treated?
Retention of placental fragments and subinvolution of uterus
b. Teach: s/s of late postpartum hemorrhage (up to 6 wks after birth):
52. What would indicate hemorrhage in the vaginal delivery? C-section?
a.
Vaginal= >500 ml
b. C-section= > 1000 ml
postpartum hemorrhage? S/s to look for?
a. Early: (w/in 24 hr after birth)
i. Uterine atony-s/s: uterus is hard to feel, boggy, fundal height is high, lochia is increased/may
53. What could cause early and late
FI s
contain clots
I n
+ 0
f-
ii. Lacerations-s/s: bright red bleeding or trickle, hard uterus
1. maybe to the cervix, perineum, vagina, or around urethra
2. seen more w/preciptous, forceps, or vacuum assisted births
3.
tx:
suturing; follow episiotomy care
iii. hematomas-s/s: severe unrelenting perineal pain that anagesics do not relieve, pressure
vulva, pelvis, or rectum, may have problems w/urination, s/s of shock, bluish or puplish
at
bulging mass
1. can be on vulva or inside vagina; can
2.
b. Late:
be seen in
prolonged labor
tx: small-ice; large-may require 1&D
(after 24 hrs of birth up to 6 wks after birth)
Retention of placental fragments-s/s: Persistent bright red bleeding, return of red bleeding
after it has changed to pinkish, brown, or white; fragments are removed by MD
=_==1.
Tx:
pitocin to contract uterus, curettage or scraping may be indicated
ii. Subinvolution of the uterus-s/s: fundal ht greater than expected, persistence of locia rubra
slowed progression through
(54,/What is subinvolution? How is it treated?
a.
Slower than expected return
b.
can be
C. Tx:
phases, pelvic pain, heaviness, fatigue
of uterus to its
nonpregnant condition
caused by infection or retained fragments
methergine to maintain firm uterine contractions, abx if infection suspected, D&C/E to remove
fragments
d.
Teach: s/s of infection (fever, persistent pain, persistent red locia or return or foul smelling vaginal
discharge, how to palpate fundus)
or
55. How do
b.
C.
d.
peuperal infections occur? s/s? tx?
after childbirth
Local infections can spread to the reproductive tract and peritoneum (i.e. endometritis)
S/s: fever (100.4 or greater) after the 1st 24 hrs and on at least : days during the 1't 10 days after birth,
THR, cramping/abd tenderness
Tx: C&S, abx, teach (hygeine, adequate rest/nutrition, report signs of infection after d/c, teach to take
ALL abx, apply peri-pads front to back, food high in protein and vit C
Infection or septcemia
a.
56. List and describe the
thromboembolic disorders associated with postpartum mothers along with interventions.
(Superficial vein thrombosis)
Involves saphenous vein
ii. s/s: painful, hard, reddened, warm vein that is easily seen
a. SVT:
analgesics, local application of heat, elevate legs
b. DVT: (Deep vein thrombosis)
iii. tx:
i.
Involves deeper veins
ii. s/s: pain, calf tendernes, leg edema, color changes, pain when walking, +Homans sign
F☆☆
(sometimes)
to SVT but w/SQ or IV heparin (or enoxaparin)
iv. anticoagulant therapy is continued for 6 wks postpartum
I
t
ill. tx: similar
C.
PE (Pulumonary embolism)
i. Pulmonary artery is obstructed by blood clot that breaks off and lodges in the lungs
ii. s/s: sudden onset chest pain, cough, dyspnea, I LOC, signs of HF, confusion, diaphoresis
tx: transfer to ICU or higher level of care; heparin IV
57. How would the nurse know a postpartum mother has mastitis?
Redness and heat in breast, edema in breast, purulent drainage (may or may not be present), fever, chills,
may have abscess, may have flu-like symptoms
58. What would be the treatment for mastitis?
a. Infection of the breast
59.
b.
Occurs 2-3 weeks after birth
C.
tx: abx,
removal of milk from breast, if abscess present-I&D needed, "pump and dump", no
during this issue, heat and warm showers to breast
weaning
Describe the following expected assessments for the uterine fundus immediately after birth:
a. Location: felt at the level of the umbilicus or slightly lower or above; descends about 1cm (fingers
breadth/width) per day (by day 10 postpartum-should not be able to palpate uterus)
b.
Consistency: firm mass; size of a
grapefruit; if boggy or soft (poorly contracted)-massage (one hand
above, one below (prevents inverting of uterus),
C.
massage in circular motion
Afterpains: intermittent uterine contractions similar to menstrual cramping; can occur more often
of
oxytocin (causes uterine contractions); decreases rapidly w/in
w/breastfeeding due to release
48hrs after birth
60. How does
massaging a boggy uterus control uterine bleeding?
Causes uterine muscles to contract which seals off blood vessels where placenta was attached to uterus
describe the
61. List and
3 stages of lochia, including the duration of each. What should be reported? Pad use?
a.
b.
Lochia rubra-red discharge made of mostly blood; birth to 3 days post
Lochia serosa-pinkish brown discharge from blood and mucus content; 3-10 days post
c. Locia alba-creamy
d.
e.
f.
62.
white, clear, colorless discharge made of mostly mucus; 10-21 days
*Lochia should have a fleshy or menstrual odor
*Lochia should be monitored frequently; if excessive discharge noted, provide a clean pad and
recheck w/in 15 minutes; pads can be counted or weighed to determine accurate output; assess
underpads as well to determine extent of discharge; pooling occurs in the mother while laying down
and lochia will be heavier once standing; small clots are expected NOT large ones; women
w/ cesareans may produce less lochia w/in 1st 24 hours; apply pads front to back
*Report foul smelling lochia, return to previous lochia stage; excessive clots; bright red trickle or
spurting
Describe the appropriate nursing teaching in the following areas for postpartum discharge:
Hygeine: daily baths/showers encouraged while lochia present; perineal care to be taught (i.e. apply
front to back, etc.) and completed w/ each voiding (BM/urination) while episiomy or laceration repair
present/healing
b.
Sexual intercourse: safe to
resume intercourse when bleeding has stopped and perineum is healed
Episiotomy: pt w/episiotomy or laceration repair should be observed for REEDA (redness, edema,
C.
ecchymosis, discharg/drainage, approximation), apply ice pack to L swelling, numb area, and
T comfort for the 1st 12-24 hrs then apply heat after the 1 st 24 hrs through use of sitz bath or warm
compresses, epifoam and benzocaine can be used to relieve perineal pain through L decreasing
inflammation and numb; perineal care to be taught and completed w/each voiding (BM/urination)
while episiomy or laceration repair present/healing (rinse perineal area from front to back
peribottle filled w/warm water or betadine solution
Infection: monitor for
d.
with
danger signs- REPORT heavy bleeding or foul smelling discharge from vagina,
breast pain or redness, elevated temp (>100.4), calf pain, persistent abdominal or pelvic pain, s/s
of
UT, infection to perineum/abdominal incision
How often should the mother be monitored for urination after delivery? What interventions can be used to
assist with voiding? When is MD notified?
a.
Regularly assist woman's bladder for distention after delivery; may not feel full to woman but uterus
appears high and deviated from midline; monitor output for the 1st 2-3 voids after delivery; f/c and/or
IVFs-monitor output until discontinued then
the
1st 2-3 voids (mainly for f/c removal)
b. Massage fundus until firm, assist woman to restroom (can provide privacy, not rush, cut on running
water, run warm water over hands while on toilet, or use peribottle to squirt warm water on
perineum to relax urethral sphincter), then once voided and measured, reassess fundus (massage if
needed); initial discomfort is normal but not a consistent buring or discomfort w/urination
4.) What is postpartum blues? Postpartum depression? What would nurses need to do to encourage expression
of
feelings?
a.
Postpartum blues-may feel let down but overall finds pleasure in life, self-limiting; for 1 st few
weeks
after birth
b.
Postpartum depression-persistent mood of unhappiness, not finding pleasure in life (lack of
enjoyment, disinterest in others, feelings of guilt or adequacy, disturbed sleep/appetite patterns,
constant fatigue, etc.); usually occurs 2-4 wks after birth; report to MD
65. What is included in the 4th stage of labor?
End part of delivery of placenta, maternal stabilization of vital signs and homeostasis, lohia scant
moderate; monitor for hemorrhage
to