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68WM6 Phs 2 Test 10

68WM6 Phs 2 Test 10 Postpartum Nursing Care

QuestionAnswer
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