Chapter 15: Caring for the Postpartal Woman and Her Family

Question 1

Postpartum care

Answer 1

begins immediately after childbirth

• the nurse assists the new mother in learning how to care for herself and her baby
• fourth stage of labor
• 6-week period (puerperium)

Question 2

Puerperium

Answer 2

postpartum
the 6 week period
-nursing assessments for the mother, the newborn, and the family

Question 3

Nursing Actions to help Achieve the Healthy People 2020 national initiative

Answer 3

center on close observation to identify hemorrhage and related complications during the critical first hour after childbirth

• ongoing education and support for women and families
• teaching about normal physiological changes during the puerperium, signs of danger, contraceptive methods, and benefits of breastfeeding empowers them to make informed decisions and choices

Question 4

Drawbacks to a shortened hospital stay approach

Answer 4

-a longer (greater than 24 hour) hospital stay provides more rest and recuperation time for the mother; a greater opportunity for postpartal education about self and infant care, and time for infant observation and assessment for anomalies, defects, or other problems and improved maternal outcomes

Question 5

Advantages for early hospital discharge

Answer 5

• decreased risk of nosocomial infections for the mother and infant
• reduced medical expenses
• opportunity for enhanced infant-family bodning

Question 6

Ensuring Safety for Mother and Infant

Answer 6

• check identification bracelets

- protect the infant from abduction

Question 7

Ensuring Safety: Check Identification Bracelets

Answer 7

safety and security must be maintained at all times during hospitalization

• placement of identification bands on both the mother and infant shortly after birth
• on bringing the infant to the mother, verify that the bracelets match
• at discharge, nurse retain both the infants parents identification bracelets as part of the permanent record

Question 8

Ensuring Safety: Protect the infant from abduction

Answer 8

must educate on various measures implemented to protect the safety of the infant

• in most facilities, infants may be transported only in a bassinet and parents are prohibited from carrying the infant in the halls
• when identification bracelets are used, they are matched before giving the infant to the mother
• instructed to give the infant only to properly identified hospital personnel
• after birth, admission photographs and footprints are taken and affixed to the permanent record
• some facilities use an umbilical cord clamp equipped with an embedded infant security alarm; the clamp, which remains in place until discharge, activates an alarm if the infant is removed from the hospital unit or if the clamp is cut or disengaged
• use of an infant electronic radio transmitter tag; a matching maternal tag is also available to ensure that the mother is correctly matched with her infant
• when two or more infants have a similar or same last name, the infants crib and charts indicate the mothers first name and a label that designates “Name alert”
• when there are multiple births, the infants cribs may be labeled with the infants name followed by a letter of the alphabet (e.g. A, B, C)
• some facilities use color-coding systems

Question 9

Early Maternal Assessment

Answer 9

• Vital Signs

- Fundus, Lochia, Perineum, Hemorrhoids

Question 10

Early Maternal Assessment: Vital Signs

Answer 10

> After Vaginal Birth:

• monitored q 15 minutes during the first hour
• q 30 minutes for second hour
• once during the third hour
• then q 8 hours until discharge or until stable

> Cesarean birth:

• every 30 minutes x 4 hours
• then every hour x 3
• then every 4 to 8 hours

Question 11

Vital Signs: Temperatre

Answer 11

98.6-100.4 degrees F
-during the first 24 hours, some may experience increased temp up to 100.4; r/t exertion and dehydration that accompany labor
>increase fluids
-greater than 101.0 degrees F = infection

Question 12

Vital Signs: Pulse

Answer 12

50-90 bpm
-heart rates of 50-70 bpm (bradycardia) commonly occur during the first 6 to 10 days postpartum
>if tachycardia occurs, could be a result of prolonged/difficult labor, blood loss, temperature elevation, or infection

Question 13

Vital Signs: Respirations

Answer 13

12-20 respirations/min

• slightly elevated can occur because of pain, fear, excitement, exertion, or excessive blood loss
• abnormal: tachypnea, abnormal lung sounds, SOB, chest pain, anxiety, or restlessness; may be indicative of pulmonary edema or emboli
• decreased respiratory rate may occur after an extremely high spinal block or epidural narcotic after a cesarean birth

Question 14

Vital Signs: Blood Pressure

Answer 14

Consistent with baseline BP during the first trimester

• elevated (anxiety, preeclampsia, essential hypertension, renal disease
• decreased (hemorrhage)
• an increase in systolic BP of 30 mm Hg or an increase in diastolic of 15 mm Hg, when associated with headaches and visual changes, may be a sign of gestational hypertension
• orthostatic hypotension can occur when person moves from a supine to sitting position

Question 15

Vital Signs: Pain

Answer 15

“fifth vital sign”

-recognized and treated in a timely manner

Question 16

Assessment: Fundus

Answer 16

within a few minutes after the birth, the firmly contracted uterine fundus should be palpable through the abdominal wall halfway between the umbilicus and the symphysis pubis
-1 hour later, the fundus should have risen to the level of the umbilicus where it remains for the following 24 hours
-fundus decreases 1 fingerbreadth (1 cm) per day in size
>immediately after birth; midline, firmly contracted and palpable through the abdominal wall midway between the umbilicus and symphysis pubis
>Abnormal: Boggy (full bladder, uterine bleeding)

Question 17

Why is Uterine assessment crucial during the first hour postpartum

Answer 17

• first hour represents the most dangerous time for the patient
• nurse conducts frequent uterine assessments
• relaxation of the uterus (atony) results in rapid, life-threatening blood loss because no permanent thrombi have yet formed at the placental site

Question 18

Assessment: Lochia

Answer 18

puerperal discharge of blood, mucus, and tissue

• Normal progression: lochia rubra (1-2 inch stain on pad, may contain small clots), consistent with a heavy menstrual period for the first 2 hours, then should usually steadily decrease, fleshy odor
• Abnormal: large amounts, clots (hemorrhage), foul-smelling (infection)

Question 19

Assessment: Episiotomy or Incision

Answer 19

> Normal: no redness, edema, ecchymosis (bruising), or discharge; edges well approximated
Abnormal: redness, edema, ecchymosis, discharge, non-approximated edges (infection)

Question 20

Assessment: Hemorrhoids

Answer 20

• Normal: none, or if present, small

- Abnormal: tender, enlarged and tense (inflammed)

Question 21

Assessment: Bladder

Answer 21

• Normal: able to spontaneously empty bladder within 6 to 8 hours, urine output at least 150 mL/hour; bladder not palpable after voiding
• Abnormal: unable to empty bladder (urinary retention), presence of urgency, frequency, dysuria (UTI)

Question 22

What if there is Lower extremity Homan’s signs

Answer 22

pain with palpation, warmth, tenderness (thrombophlebitits)

Question 23

What if there is Costovertebral angle tenderness (CVAT)

Answer 23

kidney infection

Question 24

The perineal Assessment

Answer 24

the fundus, lochia, and perineum need to be assessed every 15 minutes during the immediate postpartum period

• assist the patient to a Sims’ (side-lying) position with back facing the nurse
• provide privacy and adequate lighting
• gently lifts the buttock cheeks to visualize the perineum (REEDA; Redness, Edema, Ecchymosis, Drainage/Discharge, and Approximation)
• some edema of the vulva and perineum is common during the first few postpartum days but, excessive swelling, discoloration, incisional separation, or discharge other than lochia and complaints of pain or discomfort should be reported
• note and document number, appearance, and size (cm) of hemorrhoids

Question 25

Hemorrhoids

Answer 25

may be present before pregnancy or develop during pregnancy; can become enlarged because of pressure on the lower bowel during the second stage of labor (delivery) - application of ice packs and/or pharmaceutical preparations (topical anesthetic ointments, witch hazel pads) help to relieve discomfort - frozen tea peripads for hemorrhoids and labia swelling; the tannic acid decreases edema and is soothing - assist the patient to a side-lying position in bed, teach her to sit on flat, hard surfaces and to tighten her buttocks before sitting; soft surfaces and pillows such as donut rings should be avoided because they separate the buttocks and decrease venous flow, intensifying the pain - if develop during pregnancy, usually disappear within a few weeks after childbirth

Question 26

BUBBLE -HE Mneumonic

Answer 26

``` Breasts Uterus Bladder Bowel Lochia Episiotomy Homans sign Emotion ```

Question 27

Assessment: Breasts

Answer 27

-inspection of nipples: everted, flat, inverted? -breast tissue: soft, filling, firm? -temperature and color: warm, pink, cool, red streaked? >during pregnancy and lactation they change in size and weight

Question 28

How to Assess the breasts

Answer 28

ensure privacy and asks patient to remove bra; chest area is covered with a sheet or towel, and instructed to raise her arms and rest her hands on her head - nurse inspects and palpates each breast for size, shape, tenderness, and color; during the first 2 postpartal days= breast tissue soft to touch, by 3rd day= begin to feel firm and warm ("filling"), on 4th and 5th day= breastfeeding mothers breast should feel firm before infant feeding then become soft once baby is satiated; noticeable changes in breast firmness are indicative of milk transfer - occasionally, small, firm nodules can be palpated in the "filling" breasts; result from incomplete feeding during previous feeding; disappear after satisfactory feeding but location should be monitored and noted; persistence of any breast mass can = fibrocystic disease or malignant growths unrelated to pregnancy - documents appearance of nipples, noticing the presence of fissures, cracks, blood, or dried milk and whether they are erect or inverted

Question 29

Assessment: Uterus

Answer 29

-Location (midline or deviated to right or left side) -tone (firm, firm with massage, boggy) >immediately after expulsion of the placenta, the uterus contracts to prevent hemorrhage

Question 30

Involution

Answer 30

term that describes the process whereby the uterus returns to the nonpregnant state - results from a decrease in the size of the myometrial cells of the myometrium (muscle layer of uterus) - phagocytosis contributes to this process by removing elastic and fibrous tissue from the uterus

Question 31

What does the Uterus do immediately after the delivery of the placenta?

Answer 31

to prevent hemorrhage, rapid uterine contractions seal off the placental site, effectively pinching off the massive network of maternal blood vessels that were attached to the placenta

Question 32

Subinvolution

Answer 32

failure of the uterus to return to nonpregnant state - from multiple births, hydramnios, prolonged labor or difficult birth, infection, grand multiparity, or excessive maternal analgesia - a full bladder or retained placental tissue may prevent the uterus from sustaining the contractions needed to prevent hemorrhage or to facilitate involution

Question 33

Exfoliation

Answer 33

scaling off of dead tissue - the placental site heals by this process - new endometrial tissue is generated at the site from the glands and tissue that remain in the lower layer of the decidua after separation of the placenta - results in a uterine lining that contains no scar tissue , which could impede implantation in future pregnancies - regeneration is complete by the 16th postpartum day, except at the placental site, where regeneration is usually not complete until 6 weeks after childbirth

Question 34

How to Perform a Uterine Assessment

Answer 34

- supine position so that the height of the uterus is not influenced by an elevated position - abdomen observed for contour to detect distension and presence of striae or diastasis (separation), which appears as a slightly indented groove in the midline; when present, the width and length of a diastasis are recorded in fingerbreadths - uterus fundus is palpated by placing one hand immediately above the symphysis pubis to stabilize the uterus and the other hand at the level of the umbilicus ; nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located; it should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth

Question 35

Proper technique for uterine palpation

Answer 35

uterus should never be palpated without supporting the lower uterine segment (symphysis pubis) -failure to do so may result in uterine inversion and hemorrhage

Question 36

What doe the uterus do immediately after childbirth

Answer 36

immediately after childbirth, the uterus rapidly contracts to facilitate compression of the intramyometrial blood vessels >the fundus can be palpated midline, midway between the symphysis pubis and the umbilicus

Question 37

The fundus is assessed for what?

Answer 37

- consistency (firm, soft, or boggy) - location (should be midline) - height (1 fingerbreadths)

Question 38

After how many days will the uterus have descended into the pelvis and no longer palpable?

Answer 38

10 days | -descends at a rate of 1 fingerbreadth (cm) per day

Question 39

After pains

Answer 39

(afterbirth pains) -intermittent uterine contractions that occur during the process of involution >discomfort or similar to menstrual cramps >often severe for 2 to 3 days after childbirth -when the uterus maintains a constant contraction, the pain cease -breastfeeding and administration of exogenous oxytocin produce afterpains because both cause powerful uterine contractions >Interventions: prone position with a small pillow placed under her abdomen, sitz baths (for warmth), ambulation, and mild analgesics

Question 40

Breastfeeding and afterpains

Answer 40

analgesics such as ibuprofen (Advil or Motrin) or naproxen (Aleve and Anaprox) are administered to lessen the discomforts of afterpain -breastfeeding women should take pain medication 30 minutes before nursing the baby to achieve maximum pain relief and to minimize the amount of medication that is transferred in the breast milk

Question 41

What medications can be give for afterbirth pains?

Answer 41

-ibuprofen (Advil or Motrin) -naproxen (Aleve and Anaprox) >breastfeeding women take 30 minutes prior to feedings

Question 42

Bladder after childbirth

Answer 42

- voiding should occur within 6 to 8 hours spontaneously - output of 150 mL/hr. to avoid urinary retention and stasis - generalized edema is often present in early puerperium; r/t fluid accumulation that normally occurs during pregnancy combined with IV fluids frequently administered during labor and birth - maternal diuresis occurs immediately after birth and output reaches up to 3000 mL each day by the 2nd to 5th postpartum days

Question 43

Changes in bladder caused by pregnancy

Answer 43

- decreased bladder tone is normal during pregnancy; results from the effects of progesterone on the smooth muscle - edema from pressure of the presenting part - mucosal hyperemia (increased amount of blood in the vessels) - prolonged labor, use of forceps, analgesia, and anesthesia may intensify the changes in the postpartum period - pressure caused by the fetal head pressing on the bladder during labor can result in trauma and a transient loss of bladder sensation during the first few postpartum days or weeks; can result in incomplete bladder emptying and overdistention

Question 44

Bladder and urethral trauma

Answer 44

- not uncommon during the intrapartal period and may be associated with a decreased flow of urine immediately after a vaginal birth - an increase in the voided volume, the total flow time (how long it takes to empty the bladder), and the time to peak urine flow (maximum urinary flow rate) begins to occur during the first postpartum day - urine volume and flow time should return to prepregnant state by 2 to 3 days after childbirth

Question 45

Risks for postpartum urinary retention

Answer 45

- epidural anesthesia, catheterization before birth, and an instrument-facilitated birth - can also result from bladder hypotonia after childbirth because the weight of the gravid uterus no longer limits bladder capacity

Question 46

What can cause uterine atony and lead to hemorrhage?

Answer 46

an overdistended bladder, which displaces the uterus above and to the right of the umbilicus

Question 47

How to percuss the bladder

Answer 47

- nurse places one finger flat on the abdomen over the bladder and taps it with the finger of the other hand - full bladder= resonance sound - empty bladder= dull, thudding sound

Question 48

Interventions to help postpartum mom void

Answer 48

spontaneous voiding returns within 6 to 8 hours -until this time: enhance attempts to void >assisting patient to toilet >providing privacy in an unhurried environment >turning on the bathroom faucet >sitz bath

Question 49

Bowel

Answer 49

- GI system becomes more active after childbirth - often feels hungry and thirsty after food and fluid restrictions that accompany intrapartal experience - hormone Relaxin, which reaches high circulating levels during pregnancy, depresses bowel motility - the relaxed condition of the intestinal and abdominal muscles, combined with the continued effects of progesterone on smooth muscles, diminishes bowel motility: results in constipation during early puerperium - after childbirth, bowel movements are delayed until the second or third puerperal day

Question 50

What can be associated with painful defecation

Answer 50

- hemorrhoids - perineal trauma - presence of episiotomy

Question 51

Strategies to help prevent constipation

Answer 51

- early ambulation - abundant fluids - high-fiber diet

Question 52

Nursing Interventions to Facilitate normal bowel function during the Puerperium

Answer 52

- drink 6-8 8oz glasses of water everyday to keep stool soft - eat high-fiber diet that includes fruit and vegetables, oat and bran cereal, whole-grain bread, and brown rice - avoid ignoring urge to defecate - avoid straining to have a bowel movement - early ambulation - stool softeners or laxatives as ordered - after discharge, OTC medications may be helpful for hemorrhoidal symptoms of pain, itching, or swelling but consult with caregiver before using medications

Question 53

Lochia

Answer 53

superficial layer of the endometrium becomes necrotic and sloughs off in the uterine discharge; lochia - composed of erythrocytes, epithelial cells, blood, fragments of decidua, mucus, and bacteria - characteristics of lochia is indicative of woman's status in the progress of involution

Question 54

Lochia Rubra

Answer 54

during the first few days postpartum, the lochia consists mostly of blood, which gives it a characteristic red color known as lochia rubra -also contains elements of amnion, chorion, decidua, vernix, lanugo, and meconium (if fetus has passed any stool in utero)

Question 55

Lochia serosa

Answer 55

- after 3 to 4 days - pinkish-brownish - contains blood, wound exudates, erythrocytes, leukocytes, and cervical mucosa

Question 56

Lochia alba

Answer 56

-10 to 14 days, the uterine discharge has a reduced fluid content and composed of leukocytes -white or yellow-white thick discharge -also contains decidual cells, mucus, bacteria, and epithelial cells >present until 3rd week after childbirth but can persist for 6 weeks

Question 57

Normal Pattern of Lochia Flow

Answer 57

from lochia rubra to serosa to alba; should not be reversed - a return of lochia rubra after it has turned pink or white may indicate retained placental fragments or decreased uterine contractions and new bleeding - not contain large clots; may indicate presence of retained placental fragments that are preventing closure to maternal uterine blood sinuses

Question 58

Odor of Lochia

Answer 58

similar to that of menstrual blood | -offensive odor= infection

Question 59

Assessment of Lochia Flow: documentation

Answer 59

- Scant: blood only on tissue when wiped or 1-inch (2-5cm) stain on peripad - Light: less than 4-inch (10 cm) stain on peripad - Moderate: less than 6 inch (15 cm) stain - Heavy: peripad saturated within 1 hour

Question 60

Episiotomy

Answer 60

1-2 inch surgical incision made in the muscular area between the vagina and the anus (the perineum) to enlarge the vaginal opening before birth -Midline: straight incision extending toward anus -Mediolateral: extends downward and to the side >episiotomy edges become fused (edges have been sealed) by the first 24 hours after birth >asses for redness, edema, ecchymosis, discharge, and approximation (REEDA) and document

Question 61

Hematoma after episiotomy

Answer 61

severe hemorrhage after episiotomy is possible -complaints of excessive perineal pain should alert the nurse the possibility of a perineal, vulvar, vaginal, or ischiorectal hematoma (blood-filled swelling that occurs from damage to blood vessel)

Question 62

How to assess for perineal hematoma

Answer 62

- look for discoloration of perineum - listen for complaints or expression of severe perineal pain - observe for edema of the area - listen for expression of need to defecate (hematoma may cause rectal pressure) - gently palpate the area, and observe for the patients degree of sensitivity to the area by touch - call physician or nurse-midwife to report findings immediately, the bleeding that has produced the hematoma must be promptly identified and halted

Question 63

Early episiotomy care

Answer 63

- apply ice bag or cold pack on the perineum for the first 24 hours (wrapped in a towel or disposable paper cover to prevent a thermal injury); promotes local anesthesia and vasoconstriction while reducing edema and the incidence of peripheral bleeding - after 24 hours, use of moist heat (sitz bath) between 100 and 105 degrees F for 20 minutes, 3 to 4 times a day; increases circulation to the perineum, enhances blood flow to the tissues, reduces edema, and promotes healing - dry heat in a pack may also be used; use washcloth or gauze pad between pack and skin to prevent potential burn

Question 64

Pain: Why is heat not applied to the abdomen?

Answer 64

because of the potential for uterine relaxation and bleeding

Question 65

Muscular aches and cramps r/t physical exertions expended during labor and delivery can be relieved with?

Answer 65

- back rubs and massage | - acetaminophen (Tylenol)

Question 66

Episiotomy pain can be associated with what?

Answer 66

sitting, walking, bending, urinating, and defecating | >application of cold for the first 24 hours, heat (after 24 hours), topical anesthetics (creams, sprays), and sitz baths

Question 67

Sitz bath

Answer 67

portable unit with a reservoir that fits on the toilet - when filled with warm water, the swirling action of the fluid soothes the tissue, reduces inflammation by promoting vasodilation to the area, and provides comfort and healing - used for 20 minutes, 3 to 4 times a day - can contain medicine - relieve pain, itching, or muscle spasms

Question 68

How does the nurse assess and document pain behavior?

Answer 68

- location of the pain - type of pain: stabbing, burning, throbbing, or aching - duration of pain: intermittent or continuous

Question 69

Nursing Interventions for pain

Answer 69

administration of analgesics and patient education about other measures -suggest nonpharmacological methods for pain relief such as imagery, therapeutic touch, relaxation, distraction, and interaction with infant -administer prescribed agents such as ibuprofen, propoxyphene napsylate/acetaminophen (Darvocet-N), or oxycodone/acetaminophen (Percocet) -OTC medications or alternatives such as tea tree oil for self-care after discharge >acetaminophen or ibuprofen may be equally as effective as narcotic analgesics -reassure patient that pain and discomfort should not persist beyond 5 to 7 days and that episiotomy sutures are made of an absorbable material, they do not need to be removed

Question 70

What can has also been believed, when applied to the perineum, to help relieve the pain of an episiotomy?

Answer 70

tea tree oil >provide cooling to the wound, enhance comfort, and promote healing >if redness, increased swelling, burning, or other signs of allergic reaction occur, discontinue application immediately

Question 71

Homan's Sign

Answer 71

screening tool for deep venous thrombosis (DVT) >patients legs should be extended and relaxed with knees flexed, the examiner grasps the foot and sharply dorsiflexes it >positive= resistance or discomfort in the calf or popliteal region -other leg is assessed in same manner -presence of thrombosis -no longer a component of assessment; can lead to emboli if clot is dislodged during the assessment >a negative sign does not rule out DVT

Question 72

If suggestive of a DVT, what else must you do besides Homan's Sign?

Answer 72

venography and real-time and color doppler ultrasound

Question 73

DVT clinical signs

Answer 73

- pain in the calf - erythema (superficial reddening of skin) - warmth greater in one calf than the other - unequal calf circumference

Question 74

Emotions

Answer 74

- not unusual to have periods of happiness that are intermingled with sadness, insecurity, and depression - continued assessment of woman's emotional status - provide information regarding "baby blues"; these are temporary and common

Question 75

Blood Volume After child birth

Answer 75

-decrease in blood volume correlates with the blood loss experienced during delivery -during next few days, blood loss increases further as a result of diuresis -500 mL of blood loss that typically occurs in vaginal delivery (1000 in cesarean), results in a 1 gram (2 gram for cesarean) drop in hemoglobin >as the bodys excess fluid is excreted, the hematocrit may rise because of hemoconcentration; returned to pre-pregnancy levels by 4 to 6 weeks

Question 76

White blood cell count after childbirth

Answer 76

- increases during labor and the immediate postpartum period | - returns to normal within 6 days

Question 77

Plasma fibrinogen (clotting factor) after childbirth

Answer 77

remain elevated for first few postpartal weeks | -hematological system returns to normal by 3rd to 4th postpartal week

Question 78

Circulating levels of estrogen and progesterone after childbirth

Answer 78

decrease after delivery of placenta - the decrease signals the anterior pituitary gland to produce prolactin in readiness for lactation - in formula feeding women, prolactin levels return to normal by the third to fourth postpartal week

Question 79

After childbirth and the delivery of the placenta what happens to certain hormones?

Answer 79

hormones like human placental lactogen, cortisol, growth hormone, and insulinase fall - during early postpartum, the decline in these levels reduces the anti-insulin effects that occur during pregnancy; insulin requirements are reduced for insulin dependent women "honeymoon phase" - for many diabetics, glucose levels remain in normal range (without intervention) for the first few days after childbirth

Question 80

Neurological System after childbirth

Answer 80

-fatigue and discomfort common -anesthesia and analgesia may cause transient maternal neurological changes such as numbness in the legs or dizziness; safe guard patient as priority -headaches require further assessment; after spinal or epidural anesthesia, headaches may result from the leakage of cerebrospinal fluid into the extradural space -labor induced stress or gestational hypertension cause headaches -sitting upright may cause a headache -headaches accompanied by double or blurred vision, photophobia, epigastric or abdominal pain, and proteinuria may be signs of developing or worsening preeclampsia >implement environmental interventions: reducing room lighting and noise and limiting visitors

Question 81

What are signs that indicate developing or worsening preeclampsia?

Answer 81

headaches accompanied by double or blurred vision, photophobia, epigastric or abdominal pain, and proteinuria

Question 82

Renal System, Fluid, and Electrolytes

Answer 82

- renal plasma flow, glomerular filtration rate, plasma creatinine, and blood urea nitrogen return to normal by the second to third month after childbirth - glucose excretion increases in pregnancy by 100-fold ;return to normal after first postpartal week - pregnancy associated proteinuria (up to 1- on a urine dipstick or less than 300 mg in 24 hours) is common during pregnancy and returns to normal by 6 weeks

Question 83

Sodium levels after childbirth

Answer 83

there is a rapid, sustained natriuresis (large amount of sodium in the urine) and diuresis as the sodium and water retention of pregnancy is reversed - reversal is pronounced during 2nd to 5th puerperal day - bodys fluid and electrolyte balance restored by third postpartal week

Question 84

Respiratory System after childbirth

Answer 84

- after delivery of the placenta and decline in levels of progesterone, respiratory system return to prepregnant state - the immediate decrease in intra-abdominal pressure associated with the birth of the baby allows for increased expansion of the diaphragm and relief from the dyspnea associated with pregnancy - system returns to normal by third postpartal week

Question 85

Cardiovascular system

Answer 85

during pregnancy, the heart is displaced slightly upward and to the left - as involution occurs, it returns to normal position - cardiac output is increased for 1 to 2 hours postpartum and remains high for 48 hours; normal within 2 to 4 weeks - by 2 weeks cardiac output decreases by 30% then reaches prepregnant values 6 to 12 weeks postpartum

Question 86

What happens if physiological diuresis does not occur?

Answer 86

increased risk of pulmonary edema | >3-kg weight loss occurs during the first week postpartum

Question 87

Rho(D) Immune Globulin

Answer 87

non-sensitized women who are Rh(-) negative and have given birth to a Rh(+) positive infant should receive 300 mcg of Rho(D) immune globulin (RhoGAM) within 72 hours after given birth >should be given whether or not mother received RhoGAM during antepartum period

Question 88

Rubella Vaccine

Answer 88

- if nonimmune, MMR vaccine should be administered - avoid pregnancy for 1 month (because of the teratogenic effects associated with congenital rubella syndrome) - may briefly experience rubella-type symptoms such as lymphadenopathy (enlarged lymph nodes), arthralgia (joint pain), and low-grade fever - may be given to breastfeeding mothers - signed consent form before given

Question 89

Diastasis recti abdominis

Answer 89

term used to define the separation between the two rectus abdominis muscle that can occur from pregnancy -during early postpartal period, abdominal wall may not be protected to withstand additional stress from increased activities; maintain correct posture with activities for at least 12 weeks and perform modified sit ups to strengthen abdominal muscles

Question 90

Activity and Rest

Answer 90

- early postpartum ambulation is key in preventing thromboembolic events - begin with mild exercises; Kegel exercises to strengthen pelvic floor - non-ambulating patients should begin with leg exercises - exercising methods increase gradually - obtain adequate sleep and frequent rest periods

Question 91

Nourishment

Answer 91

- weight loss of 10 to 12 lb occurs after childbirth due to the collective weight from baby, placenta, and amniotic fluid - an additional 5lbs is lost in result of puerperal diuresis and uterine involution - eat a balanced nutritious diet with multivitamin supplements - iron only recommended if hemoglobin is low

Question 92

Elimination

Answer 92

- occur within 4 hours - empty bladder every 4 to 6 hours and expect to excrete large volumes - intake and output recorded during first 24 hours

Question 93

Teaching about Perineal Care ("pericare")

Answer 93

-fill the squeeze/ peri-bottle with tap water. water should feel comfortably warm on wrist -sit on toilet with the bottle positioned between your legs so that water can be squirted directly on perineum; aim bottle opening at your perineum and spray so that water moves front to back; no not separate the labia and do not spray the water into your vagina; empty entire bottle over perineum -gently pat the area dry with toilet paper or cotton wipes; move from front to back, use each wipe once, then drop in toilet -grasping the bottom side or ends of a clean peripad, apply it front to back -stand before flushing the toilet >rinse perineum with fresh water after use of toilet and before a new perineal pad is applied

Question 94

Pericare for Cesarean Births

Answer 94

- nurse performs - place a plastic-covered pad under patients buttocks - supine position; removes peripad in a front-to-back direction - bedpan positioned under buttocks; movement associated with lifting the buttocks helps to expel clots and/or pooled blood in vaginal canal; serves as good time to assess fundus for tone; uterine palpation helps patient expel additional blood or clots - nurse uses peri-bottle filled with warm water (or other solution according to policy) and gently squirts perineum front-to-back while allowing water to collect in bed pan - labia not separated - gently dry area and peri-pad is applied from front-to-back

Question 95

Encourage Breastfeeding in women with diabetes mellitus

Answer 95

during the intrapartal and postpartal periods, insulin requirements decrease rapidly -maternal insulin dose be decreased to avoid hypoglycemia -encourage breastfeeding and be aware that insulin requirements decrease with lactation >maternal snack before breastfeeding may prevent it

Question 96

Breastfeeding benefits for mothers

Answer 96

- decreased risk of breast, ovarian, and uterine cancer - decreased risk of type 2 diabetes mellitus - lactational amenorrhea (missed period) (LAM) (although breastfeeding is not considered an effective form of contraception) - enhanced involution (caused by uterine contractions triggered by the release of oxytocin) and decreased risk of postpartum hemorrhage - enhanced postpartum weight loss - increased bone density - enhanced bonding with infant

Question 97

Breastfeeding benefits for Infant

Answer 97

>human breastmilk is infant food choice; bacteriologically safe, fresh, and readily available, and balanced to meet the infants needs - enhanced immunity through the transfer of maternal antibodies; decreased incidence of infections including otitis media, pneumonia, UTI, bacteremia, and bacterial meningitis - enhanced maturation of GI tract - decreased risk of sudden infant death syndrome (SIDs) - decreased likelihood of developing insulin-dependent (Type 1 ) diabetes - decreased risk of childhood obesity - enhanced jaw development - protective effects against certain childhood cancers

Question 98

Breastfeeding is Contraindicated in what situations?

Answer 98

- infants with galactosemia (because of an ability to digest the lactose in the milk) - mothers with active tuberculosis or HIV infection - mothers with active herpes lesions on the nipples - mothers who are receiving medications such as lithium or methotrexate - mothers who are exposed to radioactive isotopes (e.g. during diagnostic testing)

Question 99

Supporting Women in Their feeding choice

Answer 99

- decision to breastfeed is always one that must be made by the women - choice based on what pleases her and what makes her feel most comfortable

Question 100

Board-certified lactation consultant (IBCLC)

Answer 100

health-care professional who specializes in the clinical management of breastfeeding -nurse should refer women who experience breastfeeding pain or other difficulties to a IBCLC

Question 101

Care of the Breasts during lactation

Answer 101

- wash the nipples with warm water - soap should be avoided; have drying effect and cause cracked nipples - avoid breast creams; may block the Montgomery tubercles on the areolae; other contain alcohol, a drying agent - avoid creams and oils that contain vitamin E because the infant may absorb toxic amounts

Question 102

Latch-on

Answer 102

proper attachment of the infant to the breast for feeding

Question 103

Optimal time to breastfeed

Answer 103

when the baby is in a quiet alert state >crying is usually a late sign of hunger and achieving satisfactory latch-on is difficult >most alert during first 1 to 2 hours after a unmedicated birth >bathing the neonate before the first feeding should be avoided; the smell of amniotic fluid on the infant matches the smell of the mother and serves as a "homing device" for the baby

Question 104

Benefits of the breast crawl (TBC)

Answer 104

when placed skin-to-skin on the mother's trunk, the newborn's movement toward the maternal breast is the initiation and establishment of effective breastfeeding -promotes the physical stabilization (i.e. temperature regulation, heart and respiratory rates, and blood glucose) of a healthy newborn

Question 105

Infant Feeding Readiness Cues

Answer 105

- begins to stir - bobs the head against the mattress or mother's neck/shoulder - makes hand-to-mouth or hand-to-hand movements - exhibits sucking or licking - exhibits rooting - demonstrates increased activity; arms and legs flexed; hands in a fist

Question 106

To assist the mother whose infant will not awaken to breastfeed

Answer 106

the nurse may ask: - have you tried to unwarp the baby's swaddling? (doing this will increase skin-to-skin contact and help to awaken the infant and promote feeding) - have you tried to rest with the baby by your breast? (doing this may allow the infant to feel and/or smell the breast, which may promote feeding) - are you familiar with feeding cues? Watching for feeding cues may help you to recognize when your baby is ready to breastfeed. Examples are vocalizations, movements of the mouth, and moving the hand toward the mouth. Hunger-related crying is a late sign of hunger and should not be used as the cue for feeding

Question 107

Optimal Breastfeeding Experience

Answer 107

-hold the baby so that his nose is aligned with the nipple and watch for open mouth gape -at the height of the gape, when the mouth is open widest, aim the bottom lip as far away as possible from the base of the nipple; the infants chin and the lower jaw meet the breast first and the nipple is pointed to the roof of the mouth -most of the areola should be visible from the infants top lip but not from the bottom; top and bottom lips should be flanged outward >no slurping or clicking sounds or dimpling of the cheeks >report a tugging sensation but no pain or pinching >feedings that last less than 10 minutes or longer than 40 minutes are not satisfactory

Question 108

Assessing milk let-down

Answer 108

- mother presents a tingling sensation in the nipples (not always present) - the infants quick, shallow sucking pattern transitions to a slower, more drawing pattern - exhibits audible swallowing - reports uterine cramping; increased lochia present - mother feels relaxed during feeding - opposite breast may leak milk

Question 109

Breastfeeding: Properly latched on

Answer 109

the tip of the infants nose, cheeks, and chin should all be touching the breast

Question 110

How to know if there was a good feeding?

Answer 110

- infant coming off the breast without assistance - "drunken stupor" look - nipple should be everted and round, never flat or pinched on any side - no pain from mother - infant should appear satiated

Question 111

Nipple Confusion

Answer 111

may result when breastfed infants receive supplemental feedings (bottle-fed) - require different skills - avoid bottle feeding until breastfeeding is well established (usually 3 to 4 weeks)

Question 112

Evaluation of Nourishment: Infant weight gain

Answer 112

-weight loss greater than 7% should be carefully evaluated to make sure he is being fed frequently enough and the feeding technique is effective (weight loss of 7% is NOT an "automatic" reason to supplement breastfeeding for formula) -once the mothers milk production increases and the volume of milk consumed increases; infants gain 15 to 30 g or 1/2 to 1 oz per day -as long as the baby continues to feed well and is gaining weight, the mother can be reassured

Question 113

Loss of excessive weight or failure to begin a steady pattern of weight gain indicates what?

Answer 113

the mother is not producing adequate milk or the infant is not ingesting adequate milk -can also be from the infant having other organic problems (rarely)

Question 114

Common Positions for Breastfeeding

Answer 114

- cradle hold position - football hold position - side-lying position

Question 115

Cradle hold position

Answer 115

- infant is cradled in the arm, close to the maternal breast | - infants abdomen is placed against the mothers abdomen with the mothers other hand supporting the breast

Question 116

Cross-cradle hold

Answer 116

similar to cradle hold | -infant laying in opposite direction

Question 117

Football hold

Answer 117

infants back and shoulders are held in the palm of the mothers hand - infant is tucked up under the mothers arm, keeping hip, shoulder, and ear in alignment - mother supports the breast to touch the infants lips

Question 118

Side-lying Hold

Answer 118

facing each other - can place pillow behind infants back for support - nipple should be placed in easy reach - frequent mother-baby checks (because of accidental suffocation) - ensure that newborns not left with fatigued mother in side-lying position

Question 119

Breast shells for flat, inverted, or sore nipples

Answer 119

plastic "nipple cups" or inserts that fit into the bra - may help nipples become more protuberant - may be used to prevent sore nipples from making contact with woman's clothing or bra

Question 120

Problems that result in Ineffective Breastfeeding

Answer 120

- sore nipples | - breast engorgement

Question 121

Breast Engorgement

Answer 121

excessive swelling and overfilling of the breast and areola and is a response to an increase in blood flow and an increase in milk production -occur from infrequent feeding or ineffective emptying of collecting ducts -lasts about 24 hours -range from minimal (complain of breast fullness to discomfort) to severe (pain, tenderness, hardness, warmth to touch; shiny, taut appearance; areolae become firm, nipples may flatten) >Treatment: removal of milk (via breastfeeding or pumping) to decrease stasis, which reduces swelling and discomfort (feeding q 2-3 hours) >a non-prescription anti-inflammatory drug such as ibuprofen (Motrin or Advil) can be taken for the pain and swelling r/t engorgement; take before breastfeeding in anticipation of post-feeding discomfort >wear a well-fitted supportive bra

Question 122

Infant Feedings

Answer 122

- q 2-3 hours to minimize stasis of milk | - feed at each breast at least 15 to 20 minutes until at least one breast softens after the feeding

Question 123

How to reduce swelling and enhance milk flow

Answer 123

-warm compresses and perform hand expression; softens areola, initiates let-down reflex, and allows infant to more easily grab the areola -massage breast -taking a warm shower -lean over a bowl of warm water -hand-expressing some milk before nursing >because breast swelling is r/t increased blood flow, cold ice packs may be used after breastfeeding or pumping to constrict blood flow and reduce the edema