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Quiz 4
OB
| Question | Answer |
|---|---|
| The transition period | The newborn transition period lasts 6-8 hours after birth and occurs in three phases |
| The transition period: phase 1 (first 1-2 hours) | Infant awake and alert; optimal time for breastfeeding and bonding; assess HR, RR, temp, color q15 min x4 |
| The transition period: phase 2 (quiet/sleep) | Infant may sleep for hours; gradual stabilization of vitals; continue thermoregulation support |
| The transition period: phase 3 (2-8 hours) | Meconium often passed; feeding cues emerge; complete full headto-toe assessment |
| Respiratory Adaptation | First breath is triggered by four stimuli: Chemical: Hypoxia, increased PaCO2, and acidosis from labor activate chemoreceptors Mechanical: Birth canal squeeze expels fluid from lungs; crying absorbs remaining fluid Thermal: Transition from warm to cool/dry environment stimulates the respiratory center Sensory: Touch, light, sound overload stimulates the medullary respiratory center |
| Normal Newborn Transition to Extrauterine Life notes | Normal RR: 30-60 breaths/min (irregular, shallow, unlabored) Apnea <15 seconds = normal Surfactant production begins at 24 weeks gestation - premature infants at high risk for RDS C-section alert: No birth canal squeeze, so monitor respirations more closely - fluid not expelled from lungs |
| Cardiovascular Transition: Three Fetal Shunts Must Close | Foramen Ovale (R atrium → L atrium): Increased pulmonary blood flow raises left atrial pressure, closing the valve within minutes. Becomes: Fossa ovalis Ductus Arteriosus (Pulmonary artery → Aorta): Increased O2 levels after first breath cause constriction and closure within 10-15 hours. Becomes: Ligamentum arteriosum Ductus Venosus (Umbilical vein → IVC): Cord clamping decreases blood flow, causing functional closure. Becomes: Ligamentum venosum |
| Thermoregulation | Why newborns are at risk: High body surface area to mass ratio Blood vessels close to skin surface Cannot shiver to produce heat Produce heat via brown fat (non-shivering thermogenesis) |
| Normal temp | 36.5-37.2°C (97.7-99°F) — measure axillary or temporal |
| Nursing Interventions to Prevent Cold Stress | Dry infant immediately after birth Skin-to-skin contact with parent PLUS warm blanket and hat Preheat warmers; avoid fans and drafts Delay first bath until temperature is stable (at least 1 hour of age, with stable temp) Assess temp hourly until stable |
| Immediate Nursing Interventions (First Hours of Life) | Airway: Bulb syringe - suction MOUTH then NOSE; head slightly extended APGAR: Score at 1 min and 5 min; document and communicate results ID Bands: Apply matching bands to infant and parent(s) BEFORE any separation Medications: Vitamin K (IM), Erythromycin eye prophylaxis, Hepatitis B vaccine Thermoregulation: Dry → Skin-to-skin → Hat + blanket; warm all surfaces |
| Hepatic & GI System Adaptation | Stomach capacity: 5-10 mL at birth; increases to ~60 mL by end of week 1 Meconium: Thick, dark, tarry - should be passed within 24 hours Vitamin K injection: Newborn gut is sterile and cannot produce Vitamin K; IM injection required to prevent pathological bleeding Physiologic weight loss: Expect 5-10% of birth weight in first 3-5 days; should regain within 2 weeks |
| NCLEX PEARL: Normal Newborn Transition - HIGH YIELD | APGAR at 1 & 5 min assesses IMMEDIATE status only - does NOT predict long-term cognitive ability ✓ Three shunts: Foramen Ovale, Ductus Arteriosus, Ductus Venosus - memorize what they become ✓ Prevent cold stress: Dry → Skin-to-skin → Hat & blanket. Brown fat thermogenesis, NOT shivering ✓ Immediate meds: Vitamin K (IM) + Erythromycin eye (ointment) + Hep B vaccine |
| NCLEX PEARL: Normal Newborn Transition - HIGH YIELD | ✓ C-section = no birth canal squeeze = monitor respirations more closely ✓ Suction: MOUTH before NOSE (M before N, just like alphabet) ✓ Meconium must pass within 24 hours; failure to pass = potential obstruction/Hirschsprung's ✓ Normal axillary temp: 36.5-37.2°C - assess hourly until stable |
| Vital Signs — Expected Ranges for normal newborn | heart rate: 120-160 bpm at rest; higher when crying, lower in deep sleep respiratory rate: 30-60 breaths/min; irregular, shallow, unlabored temperature: 36.5-37.2°C (97.8-99°F) — axillary or temporal; NOT rectal initially blood pressure: Not done during routine newborn assessment weight: Expect 5-10% loss in first 3-5 days; regain within 2 weeks head circumference: Normally 2-3 cm larger than chest circumference |
| Head & Cranial Assessment | Molding (asymmetric head shape): NORMAL - caused by birth canal passage; resolves in 1-2 days. Reassure parents. Caput Succedaneum: NORMAL - soft swelling crossing suture lines from pressure/vacuum; resolves within days. Reassure. Cephalohematoma: MONITOR - does NOT cross suture lines; resolves over weeks; increases jaundice risk. Notify provider if large. |
| Head & Cranial Assessment | Anterior Fontanel (open, slightly depressed): NORMAL - open until 12-18 months; slightly depressed at rest is expected Bulging/tense fontanel: ABNORMAL - suggests increased ICP. Notify provider immediately. Sunken fontanel: ABNORMAL - suggests dehydration. Assess feeding and output. Notify provider. Posterior Fontanel: NORMAL - smaller; closes by 6-8 weeks Epstein's Pearls (white specks on gum/palate): NORMAL - small inclusion cysts; resolve spontaneously. Reassure parents. |
| Eyes, Ears, Nose, Mouth | Eyes: Should be symmetrical and equal; red reflex present; no discharge (physiologic tearing absent at birth) Ears: Top of ear (pinna) should align with outer canthus of eyes; low-set ears = possible chromosomal abnormality Nose: Should be midline and patent; sneezing is common and NORMAL; newborns are obligate nose breathers |
| Eyes, Ears, Nose, Mouth | Mouth: Structures should be symmetric, intact, moist, and pink ◦ Epstein's pearls: Small white cysts on hard palate or gum line - NORMAL variant, reassure parents ◦ Intact hard and soft palate: Assess for cleft palate by visual inspection and palpation |
| Chest, Abdomen, Genitalia | Chest: Symmetrical, barrel-shaped; chest circumference 2-3 cm smaller than head circumference Abdomen: Soft, round, nondistended; umbilical stump white/grey initially ◦ Clamp removed after 24 hours; stump falls off at 1-3 weeks ◦ Keep dry; do not submerge in water until stump falls off |
| Chest, Abdomen, Genitalia | Male genitalia: Urethral meatus at tip of penis; testes palpable in scrotum Female genitalia: Labia majora covers labia minora at term (sign of maturity) ◦ Pseudomenses: Bloody or mucous vaginal discharge - NORMAL due to maternal hormones; reassure parents |
| Skin Assessment | Acrocyanosis (blue hands/feet): NORMAL transitional finding for first 24-48 hrs. Reassure. Central cyanosis (blue lips/mucous membranes): ABNORMAL - requires immediate assessment and O2. Notify provider. Lanugo (fine downy hair): NORMAL - more in preterm; reassure parents Vernix caseosa (white, cheesy coating): NORMAL - protective coating from amniotic fluid; leave or gently wipe |
| Skin Assessment | Mongolian spots (blue-gray over sacrum): NORMAL in darker-skinned infants; document carefully to avoid confusion with bruising Erythema toxicum (red blotchy rash with yellow center): NORMAL - benign rash appearing day 1-4; reassure parents; resolves spontaneously Milia (tiny white bumps on nose/chin): NORMAL - small inclusion cysts; resolve spontaneously; reassure Uric acid crystals (pink/red 'brick dust' on diaper): NORMAL - alarming to parents but harmless; reassure |
| Skin Assessment | Jaundice appearing first 24 hours: ABNORMAL - pathological jaundice; notify provider immediately Physiologic jaundice (after 24 hrs): Expected due to immature liver bilirubin conjugation; monitor levels |
| Musculoskeletal & Neurological | Posture: Arms and legs should be flexed, hands fisted (indicates good tone) Full symmetric range of motion in all extremities No clicks or clunks with hip movement (Barlow/Ortolani maneuver - assesses for developmental dysplasia of the hip) |
| Newborn Reflexes: Rooting | How to elicit: Stroke cheek/corner of mouth Normal response: Turns toward stimulus, opens mouth Disappears by: 4-6 months |
| Newborn Reflexes: Sucking | How to elicit: Place finger in mouth Normal response: Rhythmic sucking motion Disappears by: voluntary by 2 months |
| Newborn Reflexes: Moro (Startle) | How to elicit: Sudden drop of head or loud noise Normal response: arms abduct/extend then embrace (hug) Disappears by: 3-6 months |
| Newborn Reflexes: Palmar grasp | How to elicit: Place finger in palm Normal response: Fingers curl around object Disappears by: 3-4 months |
| Newborn Reflexes: Babinski | How to elicit: Stroke lateral sole of foot Normal response: Toes fan outward (Opposite of adult - normal in infant) Disappears by: 12 months |
| Newborn Reflexes: Stepping | How to elicit: hold upright, sole touches surface Normal response: walking/stepping motion Disappears by: 1-2 months |
| Newborn Reflexes: Tonic Neck (Fencing) | How to elicit: turn head to one side Normal response: arm/leg extend on face side; flex on opposite side Disappears by: 3-4 months |
| Newborn Reflexes: Extrusion | How to elicit: touch tip of tongue Normal response: infant sticks tongue out Disappears by: 4 months |
| NCLEX PEARL: Newborn Physical Exam | CRANIAL: Caput crosses suture lines (normal); Cephalohematoma does NOT cross suture lines (monitor for jaundice) Bulging fontanel = increased ICP (ABNORMAL); sunken fontanel = dehydration (ABNORMAL) Acrocyanosis (blue hands/feet) = NORMAL; Central cyanosis (blue lips) = ABNORMAL - act immediately |
| NCLEX PEARL: Newborn Physical Exam | Pseudo-menses (bloody vaginal discharge in female newborn) = NORMAL maternal hormone effect - reassure Uric acid crystals ('brick dust' on diaper) = NORMAL - key parent reassurance teaching point Epstein's pearls, milia, erythema toxicum, Mongolian spots = ALL NORMAL - reassure parents |
| NCLEX PEARL: Newborn Physical Exam | Jaundice in first 24 hours = PATHOLOGICAL (emergency); after 24 hrs = physiological (monitor) Babinski: toes fan OUT in newborn = NORMAL; toes fan OUT in adult = abnormal UMN sign Absent reflex = concern. All primitive reflexes should be present at birth. Low-set ears = possible chromosomal anomaly (Trisomy 21, Turner syndrome) |
| Signs of Respiratory Distress — Report Immediately | Grunting: Audible sound on expiration; indicates alveoli collapsing — most specific sign of RDS Nasal Flaring: Nares widen with each breath; indicates increased work of breathing Central Cyanosis: Blue color around lips/mucous membranes — NOT normal (acrocyanosis IS normal) |
| Signs of Respiratory Distress — Report Immediately | Retractions: Skin pulls inward at ribs, sternum, or neck during inhalation Apnea >15 seconds: Brief pauses are normal; >15 seconds requires intervention Stridor: High-pitched sound on inspiration; suggests airway obstruction RR >60 breaths/min (tachypnea) or <30 breaths/min (bradypnea) |
| Nursing Interventions for Respiratory Distress | Position: Head slightly extended to open airway Suction: Bulb syringe - mouth THEN nose as needed Supplemental oxygen as ordered; prepare for possible CPAP/intubation Notify provider immediately Monitor O2 saturation continuously C-section newborns: extra monitoring due to no birth canal squeeze |
| Cold Stress | Cold stress occurs when the newborn loses heat faster than it can be produced. This is a cascade that leads to hypoglycemia and metabolic acidosis. |
| Cold Stress Signs — Cluster of Findings | Decreased body temperature below 36.5°C Nasal flaring and grunting (similar to RDS — cold stress mimics respiratory distress) Hypoglycemia (from increased metabolic demand of brown fat breakdown) Lethargy and poor feeding Pallor or mottled skin |
| Nursing Interventions for Cold Stress | Rewarm gradually — skin-to-skin (kangaroo care) is preferred Place under radiant warmer if skin-to-skin not possible Cover with warmed blankets; apply hat Check blood glucose — cold stress causes hypoglycemia Delay first bath until temperature stable (at least 1 hour of age) Assess temperature hourly until stable |
| Hypoglycemia | Defined as: Blood Glucose < 40 mg/dL |
| Hypoglycemia: Risk Factors (remember SGA/LGA, DM, Stress): | Gestational age <37 weeks or >42 weeks (preterm or postterm) Maternal diabetes — infant hyperinsulinism causes rebound hypoglycemia after birth Large for gestational age (LGA) or Small for gestational age (SGA/IUGR) Maternal obesity, perinatal stress, asphyxia |
| Signs of Hypoglycemia | Jitteriness, tremors High-pitched cry Lethargy, poor feeding, hypotonia Apnea, cyanosis Seizures (severe/untreated) |
| Hypoglycemia nursing interventions | Early feeding is prevention AND treatment - breastfeed or formula feed within 1 hour of birth Caloric needs: 110-120 cal/kg/day (breastmilk and formula both approximately 20 cal/oz) Check blood glucose per protocol for at-risk infants IV dextrose (D10W) if NPO or unable to maintain glucose with feeds Notify provider if glucose <40 mg/dL |
| NCLEX PEARL: Newborn Distress Signs | Respiratory distress: GRUNTING is the most specific sign (alveoli collapsing); RETRACTIONS = increased work Apnea >15 seconds = abnormal and requires intervention; <15 seconds is normal Cold stress cascade: heat loss → brown fat burns → hypoglycemia → metabolic acidosis Hypoglycemia defined as <40 mg/dL in newborns (different from adult threshold) |
| NCLEX PEARL: Newborn Distress Signs | At-risk for hypoglycemia: IDM (infant of diabetic mother), preterm, postterm, SGA, LGA Treatment priority: Early oral feeding first, then IV glucose if needed Cold stress MIMICS respiratory distress — check temp and glucose together C-section infants: higher risk for respiratory problems - no lung fluid expulsion from birth canal |
| Uterine Involution | Involution = the process by which the uterus returns to its prepregnant size after birth. Most changes reverse within 6 weeks postpartum. |
| Uterine Involution | Immediately after birth: Uterus firm, midline, at the level of the umbilicus Rate of descent: approximately 1 cm (1 fingerbreadth) per day below the umbilicus Day 1: U/1 (1 cm below umbilicus); Day 2: U/2; Day 10: at or below pubic symphysis Returns to prepregnant size by 6 weeks postpartum Placental site heals by sloughing decidua (NOT scar tissue) — allows future pregnancies |
| Lochia stage: Lochia Rubra | timing: 1-4 days appearance: Dark/bright red; may have small clots; pregnancy debris abnormal signs: Clots > plum size; saturated pad in <15 min |
| Lochia stage: Lochia Serosa | timing: days 4-10 appearance: Lighter red, pink, or brown; old blood, WBCs, serum abnormal signs: Foul odor; sudden return of bright red bleeding |
| Lochia stage: Lochia Alba | timing: up to 6 weeks appearance: Yellow-white; WBCs, serum, mucus, bacteria abnormal signs: Foul odor; bright red blood returning |
| Lochia amount documentation (assessed per pad per hour): | Scant: ≤1 inch stain on pad Light: ≤4 inch stain on pad Moderate: ≤6 inch stain on pad Heavy: Pad completely saturated in 1 hour → REPORT IMMEDIATELY |
| Fundal Assessment: What the Nurse Does | Assess every shift and with EVERY lochia check Expected: Firm, midline, at or below umbilicus, descending 1 cm/day Boggy (soft/spongy) uterus: Indicates uterine atony → risk for postpartum hemorrhage ◦ Intervention: MASSAGE the fundus (uterine massage) ◦ If no improvement: notify provider; prepare for oxytocin administration Displaced uterus (shifted to one side): First assess and empty the bladder ◦ A full bladder is the #1 cause of uterine displacement and prevents proper contraction |
| Bladder Care (Critical Connection to Involution) | Encourage voiding every 2-4 hours to prevent bladder distension Full bladder displaces the uterus laterally and prevents contraction → leads to atony and hemorrhage If unable to void: encourage warm perineal rinse, running water, sitz bath Catheterize if unable to void after conservative measures (provider order) |
| NCLEX PEARL: Uterine Involution | Uterus descends 1 cm/day. Day 1 = U/1 (1 below umbilicus); Day 10 = at/below pubis Boggy uterus = uterine atony = PPH risk → MASSAGE FIRST, then notify provider FIRST check for a full bladder when uterus is displaced to the side Lochia: Rubra (days 1-4) → Serosa (days 4-10) → Alba (up to 6 weeks) |
| NCLEX PEARL: Uterine Involution | Heavy = saturated pad in 1 hour = REPORT; clots > plum size = REPORT Return of rubra/heavy bleeding after serosa/alba stage = ABNORMAL - report immediately Foul-smelling lochia at any stage = infection (endometritis) - report Oxytocin (Pitocin) promotes uterine contraction - know it as first-line for atony |
| BUBBLE-HE Systematic Assessment | BUBBLE-HE is the postpartum nursing assessment mnemonic. Typical assessment frequency: q15 min x4, q30 min x2, q1hr x4 hrs, then q4-8 hrs |
| BUBBLE-HE Breasts | Soft first 24 hrs; filling days 2-5 (engorgement). Assess for latch, engorgement, nipple cracks/damage. Breastfeeding: feed on demand, warm compress before, ice packs after. Non-nursing: tight bra, ice packs, NO stimulation |
| BUBBLE-HE Uterus | Firm, midline, descends ~1 cm/day. Boggy uterus = atony → massage + Pitocin. Full bladder = uterine displacement. Assess lochia with every fundal check |
| BUBBLE-HE Bladder | Encourage voiding q2-4h. Full bladder displaces uterus → prevents contraction → hemorrhage risk. Catheterize if unable to void after conservative measures |
| BUBBLE-HE Bowels | GI motility slows post-birth. Flatus + bowel sounds = adequate function. Stool softeners (docusate) PRN to reduce straining on perineum |
| BUBBLE-HE Lochia | Document: amount, color, odor, clots. See Section 4 for stages. Always assess with fundal check |
| BUBBLE-HE Episiotomy/ Perineum | Use REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation. Ice packs first 24h; then sitz baths, peri-bottle, Kegel exercises, analgesics |
| BUBBLE-HE Homans' Sign | Assess bilateral lower extremities for unilateral edema, warmth, redness, tenderness → DVT. Note: Homans sign has low sensitivity; use clinical judgment |
| BUBBLE-HE Emotions | Mood, anxiety, depression. Distinguish PP blues (normal, 1-14 days) vs. depression (persistent) vs. psychosis (EMERGENCY). Screen with Edinburgh Scale |
| Perineal Assessment & Care (REEDA) | R — Redness: Erythema beyond wound edges = sign of infection E — Edema: Swelling of perineal tissues E — Ecchymosis: Bruising or discoloration D — Discharge: Assess type, amount, and odor A — Approximation: Are wound edges together or separated? |
| Comfort Interventions (in chronological order of use): | Ice packs: First 24 hours — reduces edema and numbs pain Peri-bottle: Warm water after every void and bowel movement; clean front to back Sitz bath: Warm water 15-20 minutes for comfort and healing (after 24 hrs) Analgesics: Acetaminophen AND ibuprofen — give on a SCHEDULE, not PRN Stool softener: Docusate sodium — reduces straining and perineal pain Kegel exercises: Increases circulation to perineum; aids in healing |
| Vital Signs in Normal Postpartum Period | Temperature: Up to 38°C (100.4°F) in FIRST 24 hours is normal (dehydration from labor). Fever ≥38°C after 24 hrs = infection concern Pulse: Puerperal bradycardia (40-50 bpm) is NORMAL in first 48 hours; elevated HR = hemorrhage concern Blood pressure: Transient 5% rise in first few days; orthostatic hypotension possible first 48 hrs Respirations: Return to prepregnancy baseline; hypoventilation after C-section = epidural opioid effect |
| Hematologic Changes | Normal blood loss: Vaginal birth 200-500 mL (up to 900 mL); Cesarean 500-1000 mL (up to 1500 mL) WBC normally ELEVATES during labor and postpartum even without infection — interpret in clinical context Rh factor: If mother is Rh- and infant is Rh+, administer Rho(D) immune globulin (RhoGAM) within 72 hours of birth |
| Cesarean Birth: Additional Nursing Care | All BUBBLE-HE assessments PLUS incision and GI monitoring Incision care: Assess with REEDA at each shift; dressing removed after 24 hrs Foley catheter: Left in place until patient can ambulate (6-12 hrs) Early ambulation: As soon as feasible to reduce DVT risk and restore bowel function |
| Cesarean Birth: Additional Nursing Care | Pain management: PCA/epidural → oral analgesics; scheduled acetaminophen + ibuprofen + opioids PRN Activity restrictions: No lifting heavier than infant for 4-6 weeks; no driving on opioids Hospitalization: 2-5 days postoperative (vs. 48 hrs for uncomplicated vaginal birth) |
| NCLEX PEARL: BUBBLE-HE Postpartum Care | Full bladder = most common cause of uterine displacement and atony — empty bladder FIRST Temperature up to 38°C in first 24 hrs = NORMAL (dehydration from labor) Puerperal bradycardia (40-50 bpm) = NORMAL in first 48 hours REEDA: assess perineum every shift; note all 5 components Analgesics: Give on a SCHEDULE (not PRN) for better pain control postpartum Rho(D) immune globulin: Rh- mother + Rh+ baby → give within 72 hours, do NOT miss this window |
| NCLEX PEARL: BUBBLE-HE Postpartum Care | WBC normally elevated postpartum — do not interpret as infection without other clinical signs Mastitis: CONTINUE breastfeeding; empty breast frequently; refer for antibiotics (flu-like symptoms + red tender breast) Non-nursing mothers: tight bra, ice packs, no stimulation — DO NOT manually express milk Discharge: 48 hrs uncomplicated vaginal; 3-4 days cesarean |
| Postpartum Hemorrhage (PPH) | DEFINITION: Blood loss >1000 mL after vaginal birth OR >1500 mL after cesarean birth Primary PPH: Within 24 hours of birth Secondary/Delayed PPH: 24 hours to 12 weeks after birth |
| The 4 T's of PPH Causes: Tone (most common) | Uterine atony — failure of uterus to contract; boggy uterus on assessment |
| The 4 T's of PPH Causes: Tissue | Retained placental fragments or membranes |
| The 4 T's of PPH Causes: Trauma | Lacerations, uterine rupture, hematoma |
| The 4 T's of PPH Causes: Thrombin | Coagulopathy, DIC (disseminated intravascular coagulation) |
| Signs of PPH (by blood loss) | Early: Boggy uterus, increased lochia flow, large clots Moderate: Tachycardia (FIRST vital sign change), pallor, anxiety, weakness Late/Severe: Hypotension (LATE sign — serious), oliguria, mental status changes |
| Nursing Interventions for PPH | Fundal massage if boggy uterus Assess for lacerations or hematoma if fundus is firm (atony not the cause) Empty bladder (catheterize if needed) Establish IV access; give Oxytocin (Pitocin) first-line Quantify blood loss: weigh pads (1 mL blood = 1 gram weight) Monitor vital signs — watch for shock Know uterotonic drugs and their contraindications |
| Uterotonic Drug: Oxytocin (first line) | No contraindications for PPH; nausea, water intoxication (rare) |
| Uterotonic Drug: Carboprost (Hemabate) | CONTRAINDICATED in ASTHMA and HYPERTENSION |
| Uterotonic Drug: Methylergonovine (Methergine) | CONTRAINDICATED in CVD and HYPERTENSION |
| Uterotonic Drug: Misoprostol | Given rectally; no absolute contraindications for PPH |
| Uterotonic Drug: Tranexamic acid (TXA) | Contraindicated with coagulopathy or thromboembolic history |
| Hypovolemic Shock | Life-threatening underperfusion of organs. KEY POINT: Tachycardia appears FIRST; hypotension is a LATE sign. |
| Shock Progression — Early to Late Signs | EARLY: Tachycardia (compensatory); anxiety and restlessness; pallor; cool, clammy skin MIDDLE: Tachypnea; decreased urine output (oliguria); mental status changes LATE: Hypotension (systolic <90 or drop >40 mmHg) — very serious when this appears Treatment: 2 large-bore IVs, IV NS or LR, Foley catheter, monitor UO, labs, blood transfusion |
| Deep Vein Thrombosis (DVT) | Postpartum women have significantly elevated DVT risk due to increased clotting factors, immobility, and endothelial injury. |
| Signs of DVT | Unilateral calf pain, warmth, redness, swelling, tenderness Diagnosed by Doppler ultrasound |
| DVT nursing interventions | EARLY AND FREQUENT ambulation is the #1 prevention and priority nursing intervention Compression stockings (TED hose/SCDs) while in bed NO massage of affected limb (can dislodge clot → PE) Anticoagulation therapy as ordered (heparin/LMWH) Elevate affected extremity; warm/cold compresses |
| Pulmonary Embolism (PE) | PE is responsible for 9.2% of maternal deaths. Treat BEFORE diagnosis is confirmed. |
| PE Signs — Call 911 | Sudden dyspnea (shortness of breath) — most common presenting sign Pleuritic chest pain (sharp, worsens with breathing) Tachycardia and tachypnea Decreased O2 saturation Hemoptysis (coughing up blood) Diaphoresis (sweating) |
| Nursing Interventions for PE | CALL 911 / rapid response team immediately Supplemental oxygen — high flow IV access; anticoagulation therapy BEFORE diagnosis is confirmed Position: semi-Fowler's or high-Fowler's to ease breathing Monitor vital signs and O2 sat continuously Anticoagulation continues for approximately 6 months |
| NCLEX PEARL: PP Hemorrhage, DVT, PE | ✓ PPH definition: >1000 mL vaginal or >1500 mL cesarean — not just 'heavy bleeding' ✓ 4 T's: Tone (most common), Tissue, Trauma, Thrombin ✓ TACHYCARDIA is the FIRST sign of hemorrhage; HYPOTENSION is LATE and dangerous ✓ Boggy uterus → MASSAGE first, then Pitocin, then notify provider ✓ Hemabate/Carboprost: CONTRAINDICATED in asthma; Methergine: CONTRAINDICATED in hypertension |
| NCLEX PEARL: PP Hemorrhage, DVT, PE | ✓ DVT: NO massage of affected leg (dislodges clot → PE). Early ambulation = #1 prevention ✓ PE = 9.2% maternal deaths. Start anticoagulation BEFORE confirmed diagnosis. Sudden dyspnea is hallmark ✓ Aspirin + anticoagulants = DANGER (increased bleeding risk) — do not combine ✓ Quantify blood loss: weigh pads (1 mL = 1 gram). This is how clinical PPH is measured ✓ DIC: always SECONDARY to another cause; treat the underlying cause; prepare for ICU |
| Postpartum Blues, Depression & Psychosis: hormonal basis | After placental delivery, estrogen and progesterone drop sharply. Prolactin and oxytocin rise to support lactation. This hormonal shift is the physiologic basis for postpartum blues. |
| Postpartum Mood Disorders: Postpartum Blues (Baby Blues) | timing: Days 1-5 (up to 2 weeks); up to 80% of mothers signs/ symptoms: Tearfulness, irritability, mood swings, feeling overwhelmed, sleep/appetite disruption — SELF-LIMITING treatment/ nursing action: NORMAL — reassurance, support, rest, encouragement. Monitor for progression to depression. No medication needed. |
| Postpartum Mood Disorders: Postpartum Depression | timing: Weeks to up to 1 year after birth; 10-16% of mothers signs/ symptoms: Persistent sadness >2 weeks, inability to bond with infant, hopelessness, sleep/appetite disturbance, intrusive thoughts, possible thoughts of self-harm treatment/ nursing action: Screen with Edinburgh Postnatal Depression Scale (EPDS). Refer for therapy and/or medications (SSRIs). Support system essential. |
| Postpartum Mood Disorders: Postpartum Psychosis | timing: Within 48 hrs to 2 weeks (often days 2-3); rare signs/ symptoms: Hallucinations, delusions, confusion, rapid mood swings, disorganized thought, thoughts of harming self OR infant treatment/ nursing action: PSYCHIATRIC EMERGENCY. Hospitalize. Do NOT leave patient alone with infant. Immediate psychiatric referral. |
| Postpartum Blues — Nurse Counseling | Normalize the experience: Up to 80% of mothers experience baby blues Explain the hormonal basis — abrupt drop in estrogen/progesterone after placenta delivers Encourage support from partner, family, friends Prioritize sleep: 'Sleep when the baby sleeps' Reassure that baby blues are SELF-LIMITING and resolve within 2 weeks Instruct to CALL PROVIDER if symptoms persist beyond 2 weeks or worsen |
| Postpartum Depression — Assessment & Intervention | Use Edinburgh Postnatal Depression Scale (EPDS) for formal screening Screen at 6-week postpartum visit and any time concerns arise Risk factors: History of depression, poor social support, stressful life events, difficult birth, infant health problems Treatment: SSRIs (safe with breastfeeding), therapy (CBT), support groups Key difference from blues: DURATION (>2 weeks) and SEVERITY (impairs functioning) |
| Postpartum Psychosis — Emergency Management | This is a psychiatric emergency — hospitalization is required DO NOT leave patient alone with infant — risk of infant harm Treatment: Inpatient psychiatric care; antipsychotics, mood stabilizers Most commonly associated with bipolar disorder Onset is rapid (can occur within 48-72 hours of delivery) |
| PTSD After Birth | Risk factors: Pre-existing anxiety, history of sexual abuse, emergency C-section, severe laceration, poor support Trauma-informed care: Realize, Recognize, Respond, Resist (re-traumatization) Limit the number of providers performing exams; ask permission before procedures |
| Contraception Reminder | Ovulation may occur BEFORE the first menstrual period postpartum Breastfeeding is NOT reliable contraception unless: exclusively breastfeeding + no periods + infant <6 months (LAM - Lactational Amenorrhea Method) Discuss family planning before discharge |
| NCLEX PEARL: PP Mood Disorders | ✓ Baby Blues: up to 80% prevalence; days 1-14; SELF-LIMITING; reassure and monitor ✓ PPD: 10-16%; onset weeks to 1 year; >2 weeks of symptoms; impairs function; needs treatment (EPDS + therapy + SSRIs) ✓ PP Psychosis: RARE; onset within 48 hrs-2 weeks; hallucinations/delusions = EMERGENCY; do NOT leave alone with infant ✓ Key distinction: TIMING + SEVERITY. Blues = brief, mild, normal. PPD = prolonged, moderate-severe. Psychosis = acute, dangerous. |
| NCLEX PEARL: PP Mood Disorders | ✓ Edinburgh Scale (EPDS) = standard screening tool for PPD ✓ Breastfeeding is NOT reliable birth control unless all 3 LAM criteria met: exclusive BF + no periods + <6 months ✓ If patient says she hears voices or sees things or has urges to harm infant → EMERGENCY → call provider immediately ✓ Baby blues do NOT require medication — reassurance is the intervention; escalate if not resolving by 2 weeks |
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