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NR-NUR121 | Mother and Child Nursing (MCN) > [20] MIDTERMS | POSTPARTUM P2 > Flashcards

[20] MIDTERMS | POSTPARTUM P2 Flashcards

(35 cards)

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1
Q

COMFORT MEASURES

OXYTOCIN (PITOCIN)

  • produced by ____
  • stored in the ____
  • uterus to contract
  • control ____
  • can increase ____; always measure ____ before administering
A

OXYTOCIN (PITOCIN)

  • produced by hypothalamus
  • stored in the posterior pituitary
  • uterus to contract
  • control postpartum hemorrhage
  • can increase BP; always measure BP before administering
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2
Q

COMFORT MEASURES

OXYTOCIN

If BP >____ mm Hg:
* Withhold agent

  • Notify woman’s physician
  • prevent HTN & CVA
A

OXYTOCIN

If BP >140/90 mm Hg:
* Withhold agent

  • Notify woman’s physician
  • prevent HTN & CVA
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3
Q

COMFORT MEASURES

ACETAMINOPHEN (TYLENOL)

  • ____ Analgesic
  • 1-2 tablets PO every ____ hours PRN
  • For relief of ____
A

ACETAMINOPHEN (TYLENOL)

  • Narcotic Analgesic
  • 1-2 tablets PO every 4 hours PRN
  • For relief of mild to moderate pain
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4
Q

COMFORT MEASURE

ACETAMINOPHEN (TYLENOL)

  • Determine whether woman is sensitive to acetaminophen
  • Monitor ____, ____ & UO
  • Administer with food or after meals if GI upset occurs
  • Take ____ with tablet
A

ACETAMINOPHEN (TYLENOL)

  • Determine whether woman is sensitive to acetaminophen
  • Monitor bowel sounds, RR & UO
  • Administer with food or after meals if GI upset occurs
  • Take 1 full glass with tablet
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5
Q

COMFORT MEASURES

DOCUSATE SODIUM (COLACE, SURFAK)

  • prevent ____
  • Lower ____ of feces
  • allow ____ & water to penetrate & soften stool
A

DOCUSATE SODIUM (COLACE, SURFAK)

  • prevent constipation
  • Lower surface tension of feces
  • allow lipids & water to penetrate & soften stool
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6
Q

COMFORT MEASURES

DOCUSATE SODIUM (COLACE, SURFAK)
Possible adverse effects:

  • occasional ____
  • D____
A

DOCUSATE SODIUM (COLACE, SURFAK)
Possible adverse effects:

  • occasional abdominal pain
  • Diarrhea
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7
Q

COMFORT MEASURES

Monitoring Uterine Status

  • if (+) ____, investigate other causes

Determine relationship of fundus to umbilicus

  • Assess ____ of fundus
  • Note if fundus is in ____ or displaced to either side of abdomen
  • Record results of assessment
A

Monitoring Uterine Status

  • if (+) atony, investigate other causes

Determine relationship of fundus to umbilicus

  • Assess firmness of fundus
  • Note if fundus is in midline or displaced to either side of abdomen
  • Record results of assessment
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8
Q

COMFORT MEASURES

Monitoring Uterine Status

  • Monitor uterine status every ____ or more frequently if problems arise
A

Monitoring Uterine Status

  • Monitor uterine status every 8 hours or more frequently if problems arise
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9
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

EPISIOSTOMY HEALING
REEDA Scale:
R - ____
E - ____
E - ____
D - ____
A - ____

A

EPISIOSTOMY HEALING
REEDA Scale:
R - Redness
E - Edema
E - Ecchymosis
D - Discharge
A - Approximation

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10
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

EPISIOSTOMY HEALING
REDNESS

  • without excessive ____
  • normal ____ associated with healing
  • ____ with redness
  • infection
A

EPISIOSTOMY HEALING
REDNESS

  • without excessive tenderness
  • normal inflammation associated with healing
  • pain with redness
  • infection
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11
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

EPISIOSTOMY HEALING
EDEMA

  • ____ edema is common
  • ____ edema interferes with healing
A

EPISIOSTOMY HEALING
EDEMA

  • mild edema is common
  • severe edema interferes with healing
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12
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

EPISIOSTOMY HEALING
ECCHYMOSIS

  • few ____ bruises (common)
  • ____ bruises (interfere with normal healing)
A

EPISIOSTOMY HEALING
ECCHYMOSIS

  • few small superficial bruises (common)
  • larger bruises (interfere with normal healing)
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13
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

EPISIOSTOMY HEALING
DISCHARGE

  • ____ should be present
A

EPISIOSTOMY HEALING
DISCHARGE

  • No discharge should be present
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14
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

EPISIOSTOMY HEALING
APPROXIMATION

  • ____ should not be separated
A

EPISIOSTOMY HEALING
APPROXIMATION

  • Suture line should not be separated
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15
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

REEDA SCALE SCORING
REDNESS

  • 0 - None
  • 1 - < ____ cm of incision bilaterally
  • 2 - < ____ cm of incicion bilaterally
  • 3 - > ____ cm of incision bilaterally
A

REEDA SCALE SCORING
REDNESS

  • 0 - None
  • 1 - < 0.25cm of incision bilaterally
  • 2 - < 0.5cm of incicion bilaterally
  • 3 - > 0.5cm of incision bilaterally
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16
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

REEDA SCALE SCORING
EDEMA

  • 0 - None
  • 1 - Perineal < ____ cm from incision
  • 2 - Perineal < ____ cm from incision
  • 3 - Perineal > ____ cm from incision or affects vulvar area
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A

REEDA SCALE SCORING
EDEMA

  • 0 - None
  • 1 - Perineal < 1cm from incision
  • 2 - Perineal < 1-2cm from incision
  • 3 - Perineal > 2cm from incision or affects vulvar area
17
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

REEDA SCALE SCORING
ECCHYMOSIS

  • 0 - None
  • 1 - < ____ cm bilaterally or ____ cm unilaterally of incision
  • 2 - < ____ cm bilaterally or ____ cm unilaterally of incision
  • 3 - > ____ cm bilaterally or ____ cm unilaterally of incision
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A

REEDA SCALE SCORING
ECCHYMOSIS

  • 0 - None
  • 1 - < 0.25cm bilaterally or 0.5cm unilaterally of incision
  • 2 - < 0.25-1cm bilaterally or 0.5-2cm unilaterally of incision
  • 3 - > 1cm bilaterally or 2cm unilaterally of incision
18
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

REEDA SCALE SCORING
DISCHARGE

  • 0 - None
  • 1 - ____
  • 2 - ____
  • 3 - ____
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A

REEDA SCALE SCORING
DISCHARGE

  • 0 - None
  • 1 - Serous
  • 2 - Serosanguinous
  • 3 - Bloody, purulent
19
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

REEDA SCALE SCORING
APPROXIMATION

  • 0 - Closed
  • 1 - Skin separation < ____
  • 2 - Skin and ____ separation
  • 3 - Skin, ____, and ____ separation
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A

REEDA SCALE SCORING
APPROXIMATION

  • 0 - Closed
  • 1 - Skin separation < 3mm
  • 2 - Skin and subcutaenous fat separation
  • 3 - Skin, subcutaneous fat, and fascial separation
20
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

  • first 24 hours
  • reduce edema
  • reduce possibility of hematoma formation
  • provide numbing of the tissues
21
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

ICE PACK
Attain maximum effect:

  • Apply ice pack for approximately ____ minutes
  • Then remove for about ____ minutes
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A

ICE PACK
Attain maximum effect:

  • Apply ice pack for approximately 20 minutes
  • Then remove for about 10 minutes
22
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

  • decreases pain
  • promotes circulation to tissues
  • healing
  • reduce incidence of infection
23
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

SITZ BATH

  • Cleaning the equipment
  • Adding water to 102 to 105 F (____ C)
  • Have a ____ to pat dry perineum after the sitz bath
  • Have a clean ____ to apply
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A

SITZ BATH

  • Cleaning the equipment
  • Adding water to 102 to 105 F (38-40 C)
  • Have a clean, unused towel to pat dry perineum after the sitz bath
  • Have a clean perineal pad to apply
24
Q

COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT

SITZ BATH

  • Place a ____ within reach
  • Ask woman to use it if she feels ____ or develops difficulty ____
  • Check woman at frequent intervals
  • Water should be ____
  • Caution woman:
    -Using ____ cream or spray on her perineum
    -Who has a great deal of ____ perineal edema
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A

SITZ BATH

  • Place a call bell within reach
  • Ask woman to use it if she feels dizzy or lightheaded or develops difficulty hearing
  • Check woman at frequent intervals
  • Water should be pleasantly warm not hot
  • Caution woman:
    -Using analgesic cream or spray on her perineum
    -Who has a great deal of generalized perineal edema
25
# **COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT** **SITZ BATH** * Use sitz bath ____ x/day * Maximum of ____ minutes each time
**SITZ BATH** * Use sitz bath **3-4x/day** * Maximum of **20 minutes** each time
26
# **COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT** * Reduces perineal edema * Reduces response of nerve endings which cause perineal discomfort
COOL SITZ BATH
27
# **COMFORT MEASURES - RELIEF OF PERINEAL DISCOMFORT** **SITZ BATH** Using a bath tub: * Draw only ____ inches of water * Assess the temperature * Use water ____ * Not for bathing
**SITZ BATH** Using a bath tub: * Draw only **4 to 6 inches** of water * Assess the temperature * Use water **only for the sitz** * Not for bathing
28
# **COMFORT MEASURES** **RELIEF OF DISCOMFORT FROM IMMOBILITY AND MUSCLE STRAIN** * Reduce the incidence of complications: C____ and T____ * Promote a feeling of general well-being * Monitor any signs of ____ or ____
**RELIEF OF DISCOMFORT FROM IMMOBILITY AND MUSCLE STRAIN** * Reduce the incidence of complications: **Constipation and Thrombophlebitis** * Promote a feeling of general well-being * Monitor any signs of **dizziness or weakness**
29
# **COMFORT MEASURES** **RELIEF OF DISCOMFORT FROM IMMOBILITY AND MUSCLE STRAIN** * F____ * Effects of medications * Loss of ____ * Dizziness or faintness when woman stands up * Instruct to use ____ in the bathroom
**RELIEF OF DISCOMFORT FROM IMMOBILITY AND MUSCLE STRAIN** * **Fatigue** * Effects of medications * Loss of **blood** * Dizziness or faintness when woman stands up * Instruct to use **emergency call button** in the bathroom
30
# **COMFORT MEASURES** **RELIEF OF DISCOMFORTS LIKE BREAST ENGORGEMENT AND NIPPLE SORES** MANUAL MASSAGE * ____ her hands around the breast * Firmly slides her fingers ____ * ____ her hands to massage all areas of the breast
**RELIEF OF DISCOMFORTS LIKE BREAST ENGORGEMENT AND NIPPLE SORES** MANUAL MASSAGE * **Cups** her hands around the breast * Firmly slides her fingers **forward toward the nipple** * **Rotates** her hands to massage all areas of the breast
31
# **COMFORT MEASURES** **RELIEF OF DISCOMFORTS LIKE BREAST ENGORGEMENT AND NIPPLE SORES** * Rubbing a small amount of ____ into the nipples may aid healing * ____ are not effective and should be removed before nursing if used
**RELIEF OF DISCOMFORTS LIKE BREAST ENGORGEMENT AND NIPPLE SORES** * Rubbing a small amount of **breast milk** into the nipples may aid healing * **Ointments** are not effective and should be removed before nursing if used
32
# **COMFORT MEASURES** **RELIEF OF DISCOMFORTS LIKE BREAST ENGORGEMENT AND NIPPLE SORES** * Teach a woman to ____ daily with clear water; bath or shower and dry with a soft towel * Wear a ____; 24 hours a day
**RELIEF OF DISCOMFORTS LIKE BREAST ENGORGEMENT AND NIPPLE SORES** * Teach a woman to **wash her hands** daily with clear water; bath or shower and dry with a soft towel * Wear a **supportive and not excessively tight bra**; 24 hours a day
33
# **SAFETY MEASURES** **RESUMPTION OF ACTIVITY** * ____ daily naps are essential * 2nd week at home: resume ____ * Delay returning to work for ____ weeks; resume all activities by ____ to ____ weeks
**RESUMPTION OF ACTIVITY** * **1 or 2 daily naps** are essential * 2nd week at home: resume **light housekeeping** * Delay returning to work for **6 weeks**; resume all activities by **4 to 5 weeks**
34
# **SAFETY MEASURES** **SEXUAL ACTIVITY** Can resume if: * Healed ____ * ____ has stopped * Return to prepregnant levels of sexual interest and activity (____ months postpartum) * When ____ women experience decreased libido for several months (normal)
**SEXUAL ACTIVITY** Can resume if: * Healed **episiostomy** * **Lochial flow** has stopped * Return to prepregnant levels of sexual interest and activity (**3 months** postpartum) * When **breastfeeding** women experience decreased libido for several months (normal)
35
# **SAFETY MEASURES** **POSTPARTAL EXERCISES** * ____ should begin while in the birthing unit and to continue them at home * Help maintain ____ and ____ levels * Improve ____ fitness * Project a feeling of well-being * Increase self-esteem * Promote less fatigue
**POSTPARTAL EXERCISES** * **Simple exercises** should begin while in the birthing unit and to continue them at home * Help maintain **insulin** **and HDL cholesterol levels** * Improve **aerobic fitness** * Project a feeling of well-being * Increase self-esteem * Promote less fatigue

NR-NUR121 | Mother and Child Nursing (MCN) (26 decks)

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