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68WM6 Phs 2 Test 10
68WM6 Phs 2 Test 10 Postpartum Nursing Care
| Question | Answer |
|---|---|
| how much blood is lost during a postpartum hemorrhage? | vaginal birth-500ml, C-Section-1000ml. Marked by 10% loss of hematocrit |
| what are two causes of postpartum hemorrhage? | uterine atony and trauma |
| what is uterine atony? | lack of muscle tone that results in failure of uterine muscle fibers to contract firmly around blood vessels when placenta seperates |
| How long is the postpartum period? | begins with delivery of placenta and ends with normal mesus resumption |
| what is involution? | period of rapid healing and returning to pre-pregnant state |
| what would you check during and NSVD? (Normal Spontaneous, Vaginal Delivery | VS, breasts, uterus, bladder, lochia, perineum, lower extremities, other systems |
| what are typical VS that you would find in postpartum assessment? | elevated temp for 48hrs, BP stable, pulse-bradycardia, Resp.-normal |
| during the 1st 24hrs where is the uterus typicall found? | +/- 1-2cm above the umbilicus |
| how much urine is common in postpartum voiding? | up to 3 liters |
| how would you describe the displacement of uterus upon palpation? | upward and laterally |
| If a pt asks you about when she should expect a bowel movement postpartum, what would you tell her. | should have one in 2-3 days |
| lochia | post delivery uterine discharge- note color, odor, amount, presence of clots |
| what are the three types of lochia? | Ruba-bright red-1st couple days, Serosa-pink to brown lasting through 1st week, Alba-yellow to white lasting 10 days-2 weeks |
| r/t lochia, when should you report findings to a provider? | foul smelling, clot larger than fist, saturated pad in less than 1 hr |
| what does REEDA stand for r/t episiotomy? | Redness, Edema, Ecchymosis, Discharge, Approximation |
| what position would you ask mom to lay in to check perineum and episiotomy? | on her side, Sims, with flexed upper leg |
| what comfort measures can you take for an episiotomy? | Ice pack, topical medications, sitz bath, dry heat/heat lamp, oral analgesics |
| true or false: blood clotting factors are higher and postpartum pts are at higher risk for clot formation | True |
| If a new mom asks if her feet will return to prenatal size, what do you tell her? | Sorry momma, your feet are gonna stay that size. |
| If the new mom asks about the chloasma(mask of pregnancy) will fade and is also worried about her hyperpigmentation, what would you tell her? | Yes ma'am, it will fade and disappear |
| how soon after birth is Rhogam given? | within 72 hours |
| What pt teaching and steps would you take r/t a mother that is not Rubella immune? | Give her the immunization immediately in postpartum period and she must consent to avoid pregnancy for 4 weeks |
| what are the three phases of Rubin's psychological changes of puerperium? | phase 1: Taking in, Phs 2: Taking Hold, Phs 3: Letting go |
| what are some things you would teach the new mom r/t psychosocial adaptations? | taking care of herself, good handwashing, breast care, incision/episiotomy care, REST |
| what are some postpartum danger signs? | verbal/nonverbal passive reactions, hostile reactions, disappointment of sex of baby, lack of eye contact, non-supportive interaction between parents |
| r/t family adaption, what concerns for the mother? | primary caregiver to baby, loss of freedom, must be sensitive to concerns |
| r/t family adaption, what concerns for the father? | must involve w/teaching, involve from birth to develop bond, eager to help but not confident |
| what two drugs can be used to augment/induce labor? | prostaglandins, oxytocin |
| what three drugs can be used to ripen the cervix? | prostaglandins, misoprostol, Mag. Sulfate, endocervical gel |
| what is the action of prostaglandins r/t pregnancy? | produces contractions similar to labor, initiates "ripening" of cervix, stimulates smooth muscles |
| what pharmacological measures can be used to control hemorrhage after birth? | oxytocin, methylergonovine, prostaglandin, misoprostol |
| what is the last resort to stop postpartum hemorrhage? | hysterectomy |
| when doing an assessment for uterine atony, do you want the mom to have a full bladder or empty bladder? | empty |
| what is the second most common reason for postpartum hemorrhage and give two examples | trauma - assistive devices (vaccum, forceps) |
| what are three predisposing factors for lacerations r/t birth | rapid labor, forceps, vaccum |
| what are some s/s of a vaginal hematoma? | bulging, blue-ish or purple-ish mass of the vulva or perineum, not usually visible from outside, severe pain analgesics can not relieve, pressure on vulva, pelvis or rectum |
| what are the predisposing factors of a hematoma? | prolonged or rapid labor, large baby, use of forceps or vaccum |
| what is considered late hemorrhage? | hemorrhage later than 24 hours after delivery or 7-14 days after delivery w/o warning |
| what are the most common causes of late postpartum hemorrhage? | subinvolution, fragments of placenta still in uterus |
| what are predisposing factors for late hemorrhage? | manual removal of placenta, attempt to remove placenta before it seperates from wall, placenta accrete |
| what is subinvolution? | A slower than expected return of the uterus to its non-pregnant size after delivery |
| what are the two common reasons for subinvolution? | retained placenta and pelvic infection |
| what are s/s of subinvolution? | prolonged d/c of lochia, irregular/excessive bleeding, pelvic pain/feeling of heaviness, backache, fatigue |
| what is the progression of lochia? | lochia rubra, lochia serosa, lochia alba |
| what are three causes of Thrombosis? | venous stasis, hypercoagulation, blood vessel injury |
| what is venous stasis? | compression of the large vessels of the legs and pelvis by enlarging uterus, long time in stirrups can also cause this |
| factors that promote clot formation increased and factors that promote clot prevention increased results in what? | hypercoagulation |
| what are predisposing factors for thromboembolitic disorders? | varicose veins, obesity, oral contraceptives, smoking, women older than 35 |
| what are s/s of venous thrombosis? | swelling, redness, tenderness, warmth, enlarged cord-like veins, pain while walking |
| how would you tx superficial thrombosis? | analgesics, rest, elevate legs, elastic support, warm packs, avoid standing for long period of times, |
| s/s of DVT | swelling(legs), erythema, pedal edema, + Homan's signs, affected leg - pale&cool, chills |
| what are three ways to diagnose DVT? | ultrasoundography, doppler flow analysis, MRI |
| changes in the shape of the head to allow it to pass through birth canal | molding |
| areas of the head where sutures between the head meet. | fontanelles |
| results in localized edema (fluid) that crosses suture lines in the head | caput succedaneum |
| this is blood between the periosteum and the skull that is on one or both sides of a particular bone and does NOT cross suture lines | cephalohematoma |
| what are Epstein's pearls? | small white dots inside the mouth - normal |
| what is vernix caseosa? | thick white cream cheese-like substance. helps to determine term of baby. |
| white cysts 1-2mm in size that appear on face | milia |
| how often do you assess respirations after birth? | q 30 min |
| normal resp rate for newborn? | 30-60 p/min |
| Tachypnea | >60 resp p/min (r/t newborns) |
| define retractions & 3 examples | using accessory muscles to breath - substernal, intercostal, supraclavicular |
| most breathing "abnormalities" are normal for how long after birth? | about 1 hour |
| differentiate between central cyanosis and acrocyanosis | acrocyanosis is peripheral cyanosis(hands, feet, and mucous membranes of face) |
| one or both nasal passages are blocked or narrowed by bone or membrane? | choanal atresia |
| a newborn should void in the first ? hours | 12 |
| rooting | touching side of face with finger, baby turns head, opens mouth |
| moro reflex | infant's arms and legs extend and abduct with fingers forming a "C" |
| palmar grasping reflex | spontaneous grasp of adult finger |
| plantar grasp reflex | toes curl over when foot is touched |
| tonic neck reflex | in supine position, head turns to side and arm extends |
| babinski reflex | stroking the lateral sole of infant's foot from heel forward - toes flare out |
| dance or stepping reflex | hold infant upright and touch feet to solid surface giving appearance of trying to walk |
| what is cytotec used for and what drug classification is it? | cervical ripening and induction of labor. Prostaglandin analog |
| what are contraindications of cytotec? | prior C-section, placenta previa, acute HSV out break, any other contraindication of vaginal delivery |
| how long should a woman remain in the supine position after an endocervical gel is applied? | 15-30 min |
| what meds would you expect every baby to get upon birth? | Vit K, antiinfectives(erythromycin, tetracycline), Vaccines - Hep B |
| what does a meconium stool look like? | tarry, black, sticky-icky, odorless |
| what are 4 drugs used to tx postpartum hemorrhage? | pitocin, hemabate, cytotec, methergine |
| where are hematomas r/t birth trauma usually located? | on the vulva or inside the vagina |
| tachycardia, increased resp rate, decreased bp, pale cold clammy skin, confusion, and decreased urinary output are all s/s of | hypovolemic shock |
| what are s/s of subinvolution? | prolonged discharge of lochia, irregular or excessive uterine bleeding, pelvic pain, pelvic heaviness, backache, fatigue, malaise |
| bacterial infection after birth | puerperal infection |
| what are some postpartum depression risk factors? | marital dysfunction, anger about pregnancy, medical problems during preg, financial worries, lack of support, birth of infant with anomalies/illness, multifetal preg |
| what does a meconium stool look like? | tarry, black, sticky-icky, odorless |
| what 4 things do you measure on a newborn? | weight, avg length, head circumference, chest avg |
| what is the avg length of a newborn? | 19-21 inches 48-53cm |
| what is the normal weight range for a newborn? | 5 lb 8oz - 8 lb 13oz - AVG: 7.5 lb |
| what is the normal range for head circumference? | 33-35.5cm |
| what are the avg temp ranges for axillary and rectal? | 97.7-99.5 - 97.7-99.7 axilla preferred |
| within the first hour or so, what meds would you expect the Doc to order for a newborn? | Vit K, erythromycin |
| what do you clean the umbilical cord with? | alcohol or triple dye |
| how many ID bands are made upon birth of baby? | 4 total - 2 for baby, 1 for mom, 1 for significant other |
| 110-120 calories/kg/day is what? | Daily need for a newborn |
| what is the avg requirement of milk p/day for a newborn? | 10-21 ounces |
| A thick yellow substance high in protein, minerals, fat soluble vitamins and immunoglobulins, which transfers some immunity to the infant | colostrum |
| Appears as the milk changes from colostrums to mature milk; Immunoglobulins and protein decrease, whereas lactose, fat, and calories increase | transitional milk |
| Established by two weeks after delivery. Bluish in color and not as thick as colostrum | mature milk |
| How long should you either use breast milk or modified cow's milk(formula)? | 12 months |
| newborn characteristics that predispose them to heat loss | skin is thin and blood is close to surface, little subcutaneous/white fat, low % of subq fat, more surface area than body mass |
| what are the two types of jaundice? | physiologic and pathologic |
| when would you expect to see physiologic jaundice? | two to three days old |
| when would you expect to see pathologic jaundice? | first 24 hours |
| what is a significant level of bilirubin in a newborn? | 1.5-2 mg/dl |
| bilirubin/jaundice that crosses the blood brain barrier that causes cerebral palsy, mental retardation, hearing loss, and more subtle long-term neurologic problems | kernicterus |
| as the nurse, what risk factors are you looking for r/t hyperbilirubinemia | delayed or poor intake, cold stress, prematurity, asphyxia, infection, breastfeeding, sepsis, Rh/ABO in capability |
| s/s are benign rash of unknown cause in newborns, blotchy red areas that may have white or yellow papules or vesicles in the center; "fleabite rash" | ERYTHEMA TOXICUM |
| bluish black marks that resemble bruises, usually in the sacral area, frequent in newborns with dark skin | mongolian spots |
| pinpoint bruises that resemble a rash, increased intravascular pressure, may indicate infection or low platelet count | petechiae |
| flat, pink, or reddish discoloration, usually on face or neck, color blanches, disappear by 2 years of age | nevus simplex |
| known as port wine stain, permanent, flat, dark, reddish-purple mark, varies in size and location, can be removed by laser surgery | nevus flammeus |
| known as strawberry hemangioma, enlarged capillaries in the outer layer of skin, dark red and raised w/rough surface | nevus vasculosus |
| lacelike red or blue pattern, cold stress, overstimulation, hypovolemia, or sepsis, may indicate chromosomal abnormality | cutis marmorata |
| deep red color over half of body with pallor on the other half, usually seen w/ infants that are placed on side | harlequin color change |
| hands and feet may appear slightly blue | acrocyanosis |
| pearly white pinpoint papules on face and nose newborn due to clogged sweat and oil glands not functioning properly | milia - teach parents NOT to squeeze out |
| what are the two main types of methods for circumcision? | gomco clamp, plastibell |
| what are some therapeutic management steps you can take r/t DVT | ROM exercises w/in 8 hrs after childbirth, ambulate asap, antiembolism stockings, or SCD's, teach mom about tight pants and prolonged sitting (no good) |
| what would be the initial tx for a mom with DVT? | bedrest, elevate leg, gradual ambulation, anticoagulant therapy, analgesics, moist heat for pain |
| what are s/s of a PE | sudden chest pain, cough, dyspnea, depressed consciousness & signs of heart failure |
| what is an infection after childbirth - (episiotomy site, lacerations, uterus, urinary tract, breasts) | puerperal infection |
| what are s/s of a puerperal infection? | temp >100.4 or higher, localized redness, edema, pain, fever, malaise, loss of appetite |
| an infection of the uterine lining often at the site of the placenta | endometritis |
| s/s of endometritis | fever, chills, uterine tenderness, abd pain, foul-smelling lochia, leukocytosis after 1st day |
| what IV antibiotics would be administered to tx endometritis? | clindamycin and gentamicin |
| suprapubic pain, low-grade fever, dysuria, polyuria, chills, and spiking fever are all s/s of what? | UTI |
| prenatal age of a baby (measured in weeks) | gestational age |
| how many weeks is considered pre-term | < 38 wks |
| how many weeks is "term" | 38-42 wks |
| what is "postterm" | > 42 wks |
| what is the name of the scoring system used to assess gestational age? | Ballard Scoring System |
| what is the range of scoring on the Ballard Scoring System? lowest score to highest score | -10 to 50, -10 lowest, 50 highest |
| SGA | Small for Gestational Age |
| AGA | Appropriate Gestational Age |
| LGA | Large for Gestational Age |
| ELBW - how many grams? | extremely low birth weight - 1000g or less |
| VLBW - how many grams? | very low birth weight - 1500g or less |
| LBW - how many grams? | low birth weight - 2500g or less |
| what are three classifications for gestational age? | preterm, term, postterm |
| If the baby is showing experiencing respiratory distress and insufficient surfactant, what would you expect? | Respiratory Distress Syndrome |
| IV antibiotics, meticulous handwashing, warmth maintenance, and nutrition are steps to prevent what? | Sepsis |
| infants less than 28 weeks 1500g or less that have optical impairment is know as? | Retinopathy of prematurity |
| blood diverting from the GI tract caused by an infection in an infant is called? | Necrotizing enterocolitis |
| what are s/s of necrotizing enterocolitis? | abd distention, decreased bowel signs, vomiting, bile-stained emesis, bloody stools, abd tenderness, s/s of infection |
| what are some treatments of necrotizing enterocolitis? | antibiotics, NPO, gastric suction, parenteral nutrition, possibly surgery(ostomy) |
| what are two nursing interventions for a baby with necrotizing enterocolitis? | measure abd girth, and position baby on side so minimize pressure on diaphram |
| High levels of oxygen, oxygen-free radicals, and high positive-pressure ventilation that damage bronchial epithelium and interfere with alveolar development is what? | Bronchopulmonary Dysplasia |
| what is the result of Bronchopulmonary Dysplasia? | inflammation, atelectasis, edema, airway hyperreactivity with loss of cilia |
| what are some s/s of Bronchopulmonary Dysplasia? | Tachycardia. Tachypnea. Retractions. Rales. Wheezing. Respiratory acidosis. Increased secretions. Bronchospasm. Characteristic changes in the lungs on chest X-ray |
| what are 4 tx for BPD? | use of steriods, minimize o2, avoid fluid overload, increased nutrition, bronchodialators, diuretics, increased calories and proteins |
| what are 5 handicaps for newborn preterm babies? | inadequate respiratory function, sepsis, poor temp control, ROP, NEC, BPD, hypoglycemia, hypocalcemia |
| at what gestational age does an infant have the ability to suck and swallow? | 34 wks |
| what are heat loss factors of an infant? | think skin, lack of brown fat, larger head-greater body surface, temp control center of brain is immature, limp extended body posture, complication from heat loss |
| what are signs of heat loss in an infant? | decreased skin temp, s/s of respiratory difficulty, signs of hypoglycemia, mottled skin, lathargy, decreased muscle tone |
| what nursing interventions would you take for an infant with heat loss? | place baby in warmer, monitor skin temp, avoid cold surfaces, warmed o2, weaning to open crib |
| what are physical characteristics of a postterm baby? | thin w/loose skin, unusually alert and wide-eyed, little vernix, skin wrinkles, long nails |
| what are some problems you could expect with a postterm baby? | Asphyxia, Meconium aspiration,Poor nutrition status, higher perinatal mortality rate, Risk for low temperature, Polycythemia |
| what are 4 tx for BPD? | use of steriods, minimize o2, avoid fluid overload, increased nutrition, bronchodialators, diuretics, increased calories and proteins |
| what are 5 handicaps for newborn preterm babies? | inadequate respiratory function, sepsis, poor temp control, ROP, NEC, BPD, hypoglycemia, hypocalcemia |
| at what gestational age does an infant have the ability to suck and swallow? | 34 wks |
| what are heat loss factors of an infant? | think skin, lack of brown fat, larger head-greater body surface, temp control center of brain is immature, limp extended body posture, complication from heat loss |
| what are signs of heat loss in an infant? | decreased skin temp, s/s of respiratory difficulty, signs of hypoglycemia, mottled skin, lathargy, decreased muscle tone |
| what nursing interventions would you take for an infant with heat loss? | place baby in warmer, monitor skin temp, avoid cold surfaces, warmed o2, weaning to open crib |
| what are physical characteristics of a postterm baby? | thin w/loose skin, unusually alert and wide-eyed, little vernix, skin wrinkles, long nails |
| what are some problems you could expect with a postterm baby? | Asphyxia, Meconium aspiration,Poor nutrition status, higher perinatal mortality rate, Risk for low temperature, Polycythemia |
| when assessing the postterm infant, what will you look for? | Resp distress, hypoglycemia, hypothermia, jaundice |
| what is hydrocephalus? | Condition caused by an imbalance in the production and absorption of CSF in the ventricles of the brain |
| hydrocephalus can be a result of preexisting defects such as? | Arnold-Chiari malformation and Dandy-Walker Syndrome |
| what is Arnold-Chiari malformation? | the cerebellum and medulla extend down through foramen magnum |
| describe the Dandy-Walker syndrome | When the enlarged head involves a prominent occiput, the condition usually involves an atresia of the foramen of Lushka and Magendie |
| what would you expect to find in your assessment of a baby with hydrocephalus? | fontanel is full or bulging, head is enlarged, setting-sun is apparent |
| in infants, what is the predominant sign of hydrocephalus? | head enlargement |
| what primary methods are used to diagnose hypocephalus? | CT & MRI |
| what is the name of the shunt placed to tx hypocephalus? | Ventriculoperitoneal Shunt |
| what are the two classifications of hydrocephalus? | communicating and noncommunicating |
| define spina bifida and give the two types; | Midline defect involving failure of the bony spine to close; Spina Bifida Occulta. Spina Bifida Cystica |
| which type of spina bifida is NOT seen externally? | Spina Bifida Occulta |
| where would spina bifida occulta usually present and what can you identify externally that would clue you in? | lumbosacral area, a dimple on the back with possible tuft of hair over it |
| what are two major forms of spina bifida cystica? | meningocele(meninges and spinal fluid), meningomyelocele(contains meninges, nerve roots, spinal cord, and spinal fluid) |
| how can you diagnose neural tube defects? | MRI, Ultrasound, CT, myelography, elevated AFP, chorionic villus sampling |
| what are some nursing considerations r/t neural tube defects? | diapering, skin care, post-op care, latex-free environment, family support |
| what are some nursing interventions for a CL/CP infant? | Breck feeder(large syringe w/soft rubber tubing), feed in upright postion b/c milk will enter nasal passage=aspiration, feed slowly to burp frequently, wash away milk curds with water |
| what is PKU? | phenylketonuria- genetic disorder that causes central nervous system damage from toxic levels of amino acid phenylalanine in the blood |
| s/s of PKU: | feeding difficulties, vomiting, hypertonia, irritability, eczema and musty odor of urine |
| what type of diet would you expect to be ordered for a child w/ PKU? | fruits, veges, starches a w/phenylalanine-free protein supplement |
| when would you screen for PKU? | 24-48 hrs post birth |
| what are ways to diagnose Down Syndrome? | AFP screening, multiple marker screening, chorionic villus sampling, amniocentesis, nuchal translucency |
| what are some physical signs of Down Syndrome? | brachycephaly, small rounded skull, flat face profile, upward/outward slant of eyes, small depressed nasal bridge, high arched palate, downward curve of mouth, mouth kept open |
| how would you describe the hands, feet, chest, abd of a child w/ Down Syndrome? | hands:short/stubby, incurved fingers, feet:wide space between big toe and second toe, Chest:shortened rib cage, Abd:protruding, muscles lax and flabby, diastasis recti |
| what other problems could a child with Down Syndrome also be at risk for? | congenital heart malformation, resp tract infection, dysfunction of immune system, hypothyroidism, leukemia |
| bleeding around and into the ventricles of the brain | Periventricular-Intraventricular Hemorrhage |
| what grading scale is used with PIVH? | 1-4 with 4 being most serious |
| what are s/s of PIVH? | lethargy, poor muscle tone, decreased resp status with cyanosis or apnea, drop in Hct level, decreased reflexes |
| what nursing interventions would you take for a PIVH pt? | minimal handling, reduce environment stressors, parental support |
| what are some complications a newborn will have whose mother is diabetic? | cardiac, urinary tract, GI, neural tube defects, cardiomegaly |
| what would you expect to find in an assessment of a newborn of a diabetic mother? | resp problems, hypoglycemia, rapid resp w/ low temp and poor muscle tone |
| describe postop care for a Cleft lip baby | arm restraints, prevent from sucking or crying, prevent infection, elbow restraints, pain relief/sedation |
| describe post-op care for a cleft palate baby | lie on abd, may resume feeding, oral packing, clear to full liquids |
| what is a complex deformity of the ankle and foot; forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus? | congenital clubfoot |
| there are 4 types of clubfoot. name them | Talipes varus, talipes valgus, talipes equines, talipes calcaneus |
| plantar flexion in which the toes are lower than the heel | talipes equines |
| an inversion or bending inward or the foot | talipes varus |
| an eversion or bending outward | talipes valgus |
| dorsiflexion, in which the toes are higher than the heel | talipes calcaneus |
| this is the most common occuring clubfoot type - the foot is pointed downward and inward in varying degress of severity | talipes equinovarus (TEV) |
| heel | talus |
| pes | foot |
| equinus | extension |
| varus | bent inward |
| what are the three stages in management of clubfoot? | correction, maintenance, follow-up |
| what are the three stages DDH? (Developmental His Dysplasia | acetabular dysplasia, subluxation, dislocation |
| r/t DDH, what is Galeazzi sign? | shortening of the limb on the affected side |
| what are two other tests that are used to identify DDH? | Barlow's test and Ortolani's Sign |
| what is the harnes called that you would expect to see a child with DDH wear and how long will they 'usually' wear it? | Pavlik harness - 3-5 months |
| how is the hop joint maintained in splinting? (think position of joint and bones) | proximal femur centered in the acetabulum in an attitude of flexion |
| what are s/s of PKU in older children? | eczema, hypertonia, hyperactive behavior, mental retardation, seizures, hypopigmentation of the hair, skin, and irises. |
| what 4 drugs are most commonly used for postpartum hemorrhage? | Oxytocin, Methergine, hemabate, cytotec |
| what are nursing interventions for late postpartum hemorrhage? | assess frequently, allow rest periods, encourage intake of foods high in iron, assess for dizziness/low BP |
| s/s of postpartum depression | lack of enjoyment in life and food, disinterest in newborn and others, inability to make decisions, constant fatigue, feeling of unworthiness, suicidal feelings |
| s/s of postpartum psychosis | sleep disturbances, confusion, agitation, irritability, hallucinations, tearfulness, preoccupation with guilt, lack of appetite, excessive concern w/ baby's health |
Created by:
jrstrader
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