Exam 3 Flashcards

Question

Pain management in Labor Nonpharmacological (8)

Answer 1

* Position changes (birth ball, ambulation, chair sitting) * Massage (firm on legs and back) * Hydrotherapy (shower or tub) * Aromatherapy (lavender to distract) * Acupressure * breathing techniques (deep or hyperventilation into bag to prevent respiratory alkalosis) * Distraction * hot and cold (do not use w/ epidural)

Answer 2

- Vasa previa (vessels not in placenta) or complete placenta previa - Transverse fetal lie - Umbilical cord prolapse - Previous classical cesarean birth - Active genital herpes infection - Previous myomectomy entering the endometrial cavity

Answer 3

Use: labor induction for 1cm/hr, labor augmentation, PP hemorrhage prevention Indications - gestational age (after 41 weeks) - maternal (abruptio placentae, chorioamnionitis, preeclampsia, PROM, chronic conditions) - fetal (multifetal, IUGR, isoimmunization, demise, oligohydramnios) - control PP bleeding after placental expulsion

Answer 4

Dose: start at 0.5 mU/min and increase dose by 1 to 2 mU/min every 30 to 60 minutes until labor progresses to 1 cm/hr (more for PP) Risks - tachysystole (also r/t dehydration, violence, preeclampsia, placental abruption, meth) - FHR decelerations - Water intoxication (w/ high concentrations w/ hypotonic solutions (s/s of fluid overload: decreased urine output, edema, hypertension, pulmonary edema)-due to ADH effect - PP use: coma, seizures

Answer 5

What it includes? (all of the following) - Baseline rate 110 to 160 bpm - Baseline variability moderate - Late or variable deceleration absent - Early decelerations absent or present - Accelerations absent or present What it means? favorable so routine management-

Answer 6

What it includes? (any of the following) - Bradycardia OR Tachycardia - Minimal OR Marked baseline variability - Absent baseline variability w/o recurrent decelerations, bradycardia, or tachycardia - Absence of induced accelerations after fetal stimulation - Recurrent variable or late decelerations w/ minimal or moderate baseline variability - Prolonged decelerations b/w 2-10 minutes - Variable decelerations w/ other characteristics, such as slow return to baseline “overshoot accelerations” or “shoulders" What it means? surveillance and interventions needed

Answer 7

What it includes? - smooth sine wave in FHR baseline with a cycle frequency of 3 to 5 mins that persists for 20 mins or more (r/t opioid admin) - Absent variability w/ Recurrent late decels, recurrent variable decelerations, or bradycardia What it means? - imminent delivery or intrauterine resuscitative measures needed

Answer 8

- high alert med (use IV pump on piggyback, - stop if tachysystole (recontinue if FHR reassuring after 10-30 minutes) OR when active labor starts - Monitor EFM continuously or q15 or 5 mins in low risk - Monitor UCs for strength, frequency, duration, resting tone, maternal pain q30 minutes - Assess vitals q2h - Assess I&O q8 hrs

Answer 9

Characteristics - rounded to increments of 5 bpm during 10-minute window. - at least 2 minutes of identifiable baseline segments (not necessarily contiguous). - does not include accelerations or decelerations or periods of marked variability (amplitude greater than 25 bpm). Changes - Periodic: occur in relation to UCs. - Episodic: occur independent of UCs - Recurrent: occur in greater than or equal to 50% of the contractions in a 20-minute period. - Intermittent: occur in less than 50% of the contractions in a 20-minute period.

Answer 10

- irregular fluctuations in fetal HR - Most important predictor of fetal oxygenation regardless of accels or decels - Develops around 28-30 weeks’ gestation

Answer 11

* Absent: Amplitude range is undetectable. * Minimal: Amplitude range is visually detectable at 5 bpm or less * Moderate: Amplitude from peak to trough is 6-25 bpm * Marked: Amplitude range greater than 25 bpm.

Answer 12

After 32 weeks; 15 bpm above baseline (10 bpm above baseline if < 32 weeks) Cause: fetal movement

Answer 13

gradual periodic decrease in FHR from baseline to nadir lasting more than 30 seconds Cause: head compression

Answer 14

abrupt periodic or intermittent decrease in FHR (15 bpm or more) from baseline to nadir lasting b/w 30 seconds and 2 minutes Cause: umbilical cord compression (fetal HTN, acidemia) Key interventions - amnioinfusion if less than 60 bpm depth (contraindicated w/ vaginal bleeding, uterine anomalies, active infections, polyhydramnios) - tocolytics (terbutaline) - SVE for cord, labor progression, and fetal scalp stimulation - IURM (change position, oxygen, discontinue oxytocin)

Answer 15

gradual periodic decrease in FHR (15 bpm or more) from baseline to nadir lasting more than 30 seconds; occurs after contraction (prolonged if > 2 minutes) Cause: uteroplacental insufficiency

Answer 16

- Determine part of fetus located in fundus of uterus - Determine location of fetal back - Determine presenting part - Determine location of cephalic prominence

Answer 17

Assessments - vital and uterine activity for fever, hypotension, tachysystole - cervix for umbilical cord prolapse, rapid dilation, rapid descent of fetal head - fetal acid-base status w/ scalp or vibroacoustic stimulation Interventions - Maternal position (left or right) - IV bolus 500 mL LR - Ephedrine for hypotension - Give 10 L/min O2 via nonrebreather - Reduce uterine activity (stop oxytocin, Remove cervical ripening agent, give Terbutaline) - Amnioinfusion (contraindicated w/ active infection, vaginal bleeding, polyhydraminos) - Alter pushing efforts (q3 UCs instead of every UC) - Decrease pt. anxiety (support)

Answer 18

Mechanical - Hygroscopic dilator (dried seaweed promotes dilation by water absorption which leads to local prostaglandin release) - Transcervical balloon catheters (placed in extra-amniotic space and inflated w/ sterile water above internal os to put direct pressure on cervix); falls out once cervical dilation happens usually 6-12 hrs Pharmacological - Prostaglandin E2 (PGE2) (dinoprostone, e.g., Prepidil gel or Cervidil insert) - Prostaglandin E1 (PGE1) (misoprostol, e.g., Cytotec)

Answer 19

- Ruptured membranes (relative) - regular contractions or tachysystole - unexplained vaginal bleeding - Active herpes - Fetal distress (malpresentation, nonreassuring FHR) - hx of prior traumatic delivery, uterine myomectomy w/ the endometrial cavity or cesarean delivery esp transverse scar (no prostaglandins in TOLAC) - Vasa or Placenta previa

Answer 20

Indication - little to no cervical effacement - bishop score (< 6)- r/t fetal station, dilation, effacement, position and consistency of cervix) Nursing care - Ensure HCP gets informed consent - Continuous FHR and UC monitoring (4 hrs after intravaginal misoprostol, 2 hrs after oral misoprostol, 15 mins after insert removal) - Delay oxytocin for 30-60 mins after removal of insert (4 hrs after last misoprostol dose) - for insert, pt in supine or lateral for 2 hrs after insert

Answer 21

Uterine contractions and progressive cervical change between 20 and 37 weeks gestation due to decidua and fetal membrane activation, stress, uterine distention, Signs and symptoms - Contractions > q10 min for more than 1 hour (may be painful or painless) - Discomfort (Abdominal cramping, low back pain, menstrual-like cramps, suprapubic/pelvic pressure) - Vaginal discharge (ROM, increased amount) - cervical change (80% effacement, dilation 2cm or more)

Answer 22

o Cerebral palsy o Hearing and vision impairment o Chronic lung disease o Sepsis o Poor growth

Answer 23

- hx PTB (most important) - IVF - Behaviors: smoking, substance abuse, multiple sexual partners, hx of DES exposure - poor health (low/high BMI, low SES, anemia, infection, inflammation) - pregnancies < one yr apart - Extreme ages (very young, very old) - uterine or cervical abnormalities (short cervix, distention due to multiple fetus; Hydramnios or oligohydramnios) - Inadequate support (IPV, late Prenatal care, unmarried) - Stress - Chronic health conditions (HTN, DM, clotting disorders, abnormal lipid metabolism)

Answer 24

- education is key (bedrest - Teach pt about timing/palpation of contractions, may be painless - Document FHR baseline and note any patterns b-c FHR lower in preterm since CNS less developed - Identify and treat infections - UTI/STDs - Encourage Hydration - care for in antenatal unit (bedrest, tocolytics, stopping sexual stimulation no longer recommended routinely) - may use progesterone or tocolytics to prevent PTL w/ observation

Answer 25

Goal: prolong labor 48-72 hours to give steroids time to increase lung maturity Types - Magnesium sulfate: - Beta-adrenergic drugs – Terbutaline, Ritodrine - Calcium channel blockers – Nifedipine - Prostaglandin synthesis inhibitors – Indomethacin

Answer 26

- dilated > 6cm - preeclampsia with severe features or eclampsia - maternal bleeding w/ hemodynamic instability - infection (chorioamnionitis) - cardiac disease - fetal distress or demise (IUFD, lethal anomaly, nonreassuring fetal status) - PROM

Answer 27

- hot flashes, sweating, flushing - burning at IV site - NV - dry mouth - drowsiness, lethargy - blurred vision - hypocalcemia -> muscle weakness and loss of DTRs - SOB and respiratory depression - transient hypotension - headache - pulmonary edema and chest pain - Cardiac arrest

Answer 28

Antidote: calcium gluconate Contraindication: myasthenia gravis Care - give for 12-24 hrs after contractions cease (do not give > 5-7 days) - maintain therapeutic level of 4-7 mEq/L - 1-hr checks (DTRs, respiratory rate) - stop if <95% O2sat, <12 RR - strict I&O - do not give w/ CCBs

Answer 29

Use - seizure prophylaxis w/ preeclampsia via relaxation of smooth muscle - slow or stop premature labor - protect brains of premature babies Dose - 40g in 1000 mL IV - Loading dose: 4 – 6 g over 20 – 30 min - Maintenance dose: 1 - 4 g/hr

Answer 30

- Tachycardia - hypokalemia -> chest discomfort (palpitations, dysrhythmias, SOB) - Tremors - CNS (Headache, dizziness, nervousness) - nasal congestion - N&V - hyperglycemia - hypotension

Answer 31

Fetal Side effects - tachycardia - hyperinsulinemia - hyperglycemia When to notify provider - HR > 130 -- need ECG monitoring - BP <90/60 - Pulmonary edema - FHR > 180 bpm

Answer 32

Action: relax smooth muscle and cause bronchodilation Dose: 0.25 mg q4h SubQ for no more than 24 hrs Contraindications (anything that relaxes smooth muscles) - cardiac disease sensitive to tachycardia - GDM - hyperthyroidism - hemorrhage - seizure disorders

Answer 33

Action: relax smooth muscle for tocolysis or maternal hypertension Dose: 10-20 mg q3-6h PO (no more than 24 hrs) Side effects - hypotension (maternal and fetal) - headache - flushing - maternal tachycardia - dizziness and nausea

Answer 34

Contraindications - hypotension - aortic insufficiency (any preload-dependent cardiac lesions) Nursing care - help ambulate - do not give w/ terbutaline or mag sulfate - monitor hepatic enzymes

Answer 35

Action: prostaglandin inhibitor for tocolysis Maternal Side effects - gastritis (NV) - esophageal reflux Fetal side effects - Premature closure of fetal ductus arteriosus - intraventricular hemorrhage - oligohydramnios - necrotizing enterocolitis in preterm newborns Contraindications - Platelet dysfunction of bleeding disorder - hepatic or renal dysfunction (hepatitis) - gastrointestinal ulcerative disease - asthma (in women with hypersensitivity to aspirin)

Answer 36

Indication: Prevent/reduce severity of neonatal respiratory distress syndrome b/w 24- and 34-weeks gestation if risk for PTB in 7 days Action: Stimulates fetal lung maturity and helps w/ neuroprotection Dosage and Route: Betamethasone – 12mg IM, two doses 24 hours apart Dexamethasone – 6mg IM, four doses 12 hours apart Maternal and fetal effects - increase in WBC count - hyperglycemia (lasts 72 hrs) - decrease in fetal breathing in body movements (lasts 72 hrs)

Answer 37

Assessment - malpresentation - fetal and/or early neonatal loss - dilation 4 cm or more Care - neonatal resuscitation - mag sulfate to prevent/reduce neonatal neurologic sequelae

Answer 38

- transverse (horizontal) - best prognosis - Classical (vertical) - unable to TOLAC; used for PTL

Answer 39

- Establish IV and foley catheter access - Labs: CBC, Type & Cross - Uterine assessment and abdominal prep - Assist w/ anesthesia: Epidural (if was laboring), Spinal (if planned c-section), CSE - Pre-op meds: Reglan (metoclopramide), Bicitra (sodium citrate- lowers acidity of stomach contents), antibiotics - Transfer to OR suite and call neonatologist/NICU (if needed), - Circulating nurse duties (Intraoperative nursing care; surgical tool count)

Answer 40

- Avoid infection / sepsis (Hand-washing, keep incision dry, check lochia for odor) - Avoid respiratory stasis (Deep breathing, coughing, incentive spirometer) - Prevent DVT thrombosis r/t hypercoagulability (SCDs, Leg rollers, leg exercises, ambulation ASAP) - Prevent GI effects (gas, constipation, ileus) via monitor for abd distention, bowel sounds, flatulence, Stool softener (Colace), laxatives (Ducolax), rocking chair, ambulation

Answer 41

Diet - clear liquids (no solids until peristalsis returns) - avoid straws and carbonated beverages b/c cause gas pain Education - rocking chair to relieve gas pain - prevent constipation (enema if no BM by day 3) - may have NV

Answer 42

General care - Recovery assessments – fundus q15min (same as for SVD) - Monitor incisional bandage for bleeding and intactness - Splinting with pillow or binder to assist w/ coughing, ambulation and prevent undue pressure - foley for 12-24 hrs - clean incision w/ mild soap (no lotions)

Answer 43

- One lower uterine transverse incision - more than one, twin pregnancy, or induction of labor WITH appropriate counseling - facility must be able to do emergency c/s - low risk (normal BMI, term pregnancy, normal birth weight, avg. maternal age, spontaneous labor)

Answer 44

Benefits - shorter hospital stay - fewer complications (hemorrhage, thromboembolism, infection) - fewer neonatal breathing problems - Reduced consequences of multiple c-sections (hysterectomy, bowel or bladder injury, transfusion, infection, placenta previa or placenta accreta) RIsks - rupture of the uterus and associated sequelae (hemorrhage, hypovolemic shock, bladder/bowel injury, hysterectomy; HIE for baby) - hypovolemia and need for blood transfusions - maternal bladder or bowel lacerations

Answer 45

Risk - Aspiration (4 effects: hypoxia by airway obstruction, surfactant dysfunction, chemical pneumonitis, pulmonary hypertension) Risk Factor: post-term (> 41 weeks)

Answer 46

Cause - Neural stimulation of GI tract (fetal hypoxic stress) - Vagal stimulation of head or spinal cord compression = peristalsis and rectal sphincter relaxation Management - wipe mouth and face; no rigorous suctioning (use bulb) - No intrapartum suctioning OR routine intubation regardless of severity - Alert NICU team so full resuscitation skills (endotracheal intubation) available

Answer 47

infection of placenta and membranes Cause: bacteria from vagina moves into uterus Risks - neonatal infection - PTL - HIE (Hypoxic-ischemic encephalopathy) - cerebral palsy - periventricular leukomalacia

Answer 48

- Low parity - Invasive procedures (excess vaginal digital exams and intrauterine monitors) - meconium-stained fluid - infection (GBS, STIs) - amniocentesis

Answer 49

- fever - fetal tachycardia (bradycardia possible), - WBC (>15,000) - purulent or foul smelling discharge from cervical os - low glucose or positive amniotic fluid culture Treatment - antipyretics - antibiotics

Answer 50

- Shoulder dystocia - Prolapse of umbilical cord - Vasa previa/ruptured vasa previa - Rupture of the uterus - Anaphylactic syndrome/amniotic fluid embolism - Disseminated intravascular coagulation (DIC)

Answer 51

Appearance - Cord below presenting part through the introitus or into vagina - May be occult and palpable through membranes Risks: hypoxia Risk factors - polyhydramnios - multiple gestation - ROM or PROM when presenting part not engaged

Answer 52

- Check FHR after ROM - Elevate the presenting part off of cord - Position (knee-chest, Trendelenburg) - O2 - IV fluid - discontinue Pitocin, consider tocolytic (terbutaline to stop contractions) - Must expedite delivery, usually by c/section

Answer 53

Causes: - anterior shoulder unable to pass under pubic arch - Fetopelvic disproportion (FPD) - Maternal pelvic abnormalities Risk Factors: - Maternal diabetes - previous history of shoulder dystocia - prolonged 2nd stage of labor - fetal macrosomia (>4.5 kg) - excessive weight gain

Answer 54

Neonatal Complications - Birth injury -brachial plexus injury, fracture of clavicle/humerus - asphyxia r/t neck compression - hyperbilirubinemia - neonatal encephalopathy if > 5 min delay b/w head and body delivery Maternal complications - Hemorrhage - vaginal/rectal injury (symphyseal separation, 4th degree lacerations) - infection - peripheral neuropathy

Answer 55

- Slowing of descent into the pelvis - Development of caput on baby’s head (swelling) - Turtle sign (head sucks back in after delivery of head)

Answer 56

- call for assistance - instruct patient not to push unless directed - McRoberts maneuver (legs hyperflexed against the abdomen; opens the pelvic outlet and straightens the sacrum)- 2 people - suprapubic pressure w/ palm or fist (NO FUNDAL PRESSURE to prevent uterine rupture)

Answer 57

- Gaskin all-fours for woman - Woods corkscrew maneuver (rotate posterior shoulder out then anterior) - episiotomy extension (not preferred b-c bone issue not tissue issue) - Zavanelli maneuver (rare; head replacement then c-section)

Answer 58

Pathophysiology: disruption of maternal-fetal interface exposes vascular system and allows amniotic fluid into maternal blood stream leading to cardiopulmonary collapse/arrest S/s - change in LOC - negative inotropism (decreased cardiac output and shock) - pulmonary edema and vasospasm - severe sudden hypoxia and ARDS (dyspnea) - massive fibrinolysis

Answer 59

Pathophysiology - impaired coagulation and bleeding/hemorrhage r/t platelet and clotting factor consumption AND fibrinolysis - multi-organ ischemia r/t mucrovascular thrombosis from endothelial damage Labs - decreased platelets - increased aPTT and PT - increased D-dimer

Answer 60

- placental abruption - Amniotic Fluid Embolism - sepsis - acute fatty liver of pregnancy - dead fetus syndrome (prolonged retention of fetus/stillbirth) - severe preeclampsia - HELLP - hemorrhage

Answer 61

Temperature: < 35 or > 38 SBP: < 90 or > 160 DBP: >100 HR: <40 or > 120 RR: <10 or >30 O2 sat: < 95% LOC Changes: Agitation, confusion, unresponsive Output: <35 mL/hr for 2 hrs or more

Answer 62

Patho: uterus returns to prepregnancy size, shape and location through uterine contractions, atrophy of the uterine muscle, and a decrease in size of uterine cells. Fundal height - Immediate after birth = midway b/w umbilicus and symphysis pubis - 12 Hours PP: @ umbilicus or 1 cm above - 24 hours PP: 1 cm below umbilicus - After Day 1: Uterus decreases by 1 cm/day (1 finger) - 14 days: Below symphysis pubis, no longer palpable - 6-8 weeks: Pre-pregnant size.

Answer 63

Factors - retained placental fragments - infection (endometritis) - fibroids Manifestations - Soft and larger than normal uterus - Lochia returns to rubra and is heavy. - Back pain

Answer 64

- contractions (for PP hemostasis r/t release of oxytocin)- prevent PP hemorrhage) - afterpains (moderate to severe cramping; more noticeable in multipara; decreased after 3rd PP day) - Lochia: bloody discharge from uterus (RBC, sloughed off endometrial tissue, epithelial cells, bacteria)

Answer 65

- Decreased Placental hormones (estrogen, progesterone) by 3 weeks - Lactating women-prolactin levels increase by 3 weeks (suppresses menses) - lactating women- oxytocin released causing let-down reflex when infant nurses - Menses returns 7-9 wks PP if not breastfeeding, 4 months if breastfeeding - anovulatory until 4th menses cycle

Answer 66

- bladder distention can lead to uterine atony (displaced fundus) - Postpartum Fluid Loss via extreme diuresis (3000 mL; 150 mL q2-4 hrs) and diaphoresis r/t decreased estrogen (resolves 12 hr s PP) - decreased sensation to void and incomplete emptying r/t increased bladder capacity, pushing, epidural effects - transient stress incontinence (resolves in 6wk-3m PP

Answer 67

General - Immediately after birth till 14 hr. PP = full, soft, nontender - 2nd day PP = slightly firm nontender - 3rd day PP = Larger, firm, warm, tender, throbbing pain due to increase in vascular and lymphatic system. - Engorgement ends in 24-48 hrs. Breastfeeding - Before lactation - colostrum ( high protein and antibodies) - mature Milk will come in 72 – 96 hours after birth - engorgement can recur in breastfeeding who miss feedings, have inadequate removal of milk.

Answer 68

Breastfeeding care - feed on demand and q2-3 hrs to prevent milk stasis - stimulate milk flow w/ breast massage or warm compresses - increase calories 500-1000 per day - watch for s/s of mastitis or plugged milk ducts (tender, pea-sized lumps) Non-breastfeeding care - good support bra 24 hrs/day - cold compresses - avoid stimulation (no heat or pumping)

Answer 69

- Blood loss (Vaginal-200-500 mls AND cesarean-500-1000 mls) - Physiologic edema - Stroke volume and Cardiac output increases for 24-48 hours ( pre-pg levels w/n 10 days) - transient anemia that resolves by 8 weeks (hct < 32, Hgb <11) r/t plasma volume increase from extracellular to intravascular - Risk for thromboembolism r/t pregnancy being a hypercoagulable state (clotting factors return to normal in 2 weeks) - PP chills right after birth r/t vascular instability. - Risk for orthostatic hypotension (normal after 1 week)

Answer 70

- due to elimination of uteroplacental circulation (decrease in uterine blood flow and shift of nearly 500 ml from uteroplacental bed) - due to loss of placental endocrine function - due to mobilization of extravascular water into intravascular space (Plasma loss > RBC loss, reverses hemodilution of pregnancy)

Answer 71

Temperature - 38°C is common in 1st 24 hours r/t exertion of L&D, dehydration, hormones - Temp of > 38° C(100.4 F) after 1st 24 hours = infection Blood Pressure - Usually normal (decrease = hypovolemia, increase = PP preeclampsia) - may have transient 5% increase in systolic and diastolic BP Respirations - normal Pulse - Bradycardia (>100 = hemorrhage, hypovolemia or infection

Answer 72

Breasts (breastfeeding) Uterus/Fundus Bladder elimination Bowel elimination Lochia Episiotomy (perineum) Homan’s Sign/Lower extremities (calf pain w/ dorsiflexion = DVT) Emotional state (comfort, pain, attachment) Timing - done q15 min for 1st hr, then q30 min for 2nd hr, q4 for 22hr, every shift after 24 hrs

Answer 73

- Hgb/Hct increases - WBC increases (12,000-25,000) (leukocytosis of puerperium may mask acute postpartum infections, thrombophlebitis) - Pre-pregs level by 7 days PP - If rubella nonimmune, need to be immunized for rubella prior to discharge. - If Maternal Rh (neg) blood type with neg direct Coombs, Rh pos newborn: mother needs Rhogam within 72 hours (no rhogam for rh- infant)

Answer 74

- multiparity - rapid or prolonged labor - assistive birth (forceps, vacuum, c-section, large episiotomy, tocolytics or halogenated anesthetics) - ROM > 24hrs r/t infection risk - conditions (preeclampsia, Chorioamnionitis or intra-amniotic infection) - previous PPH or uterine surgery - Uterine overdistention (macrosomia, multiple gestation, polyhydramnios) - Placental abnormality (succenturiate lobe, placenta previa, placenta accreta, abruptio placentae, hydatidiform mole) - fetal demise

Answer 75

Factors - Overdistended uterus (macrosomia, hydramnios, multiples) - Anesthesia - High parity (> 5) - Rapid, Prolonged, dysfunctional(induced) labor - fibroids Interventions - maintain uterine tone (fundal massage) - prevent bladder distention (s/s fundus displaced from midline; empty bladder)

Answer 76

Factors - retained placental fragments esp if manual removal - Acreta, increta, percreta (unusual placental adherence-doesn’t easily separate) - placenta Abruption or Previa Signs and symptoms - Subinvolution of uterus (remains larger than normal) - Profuse bleeding after 1st week PP - Pale skin or blue discoloration Interventions - may need D& C by provider

Answer 77

Factors - operative (forceps, vacuum) - Vaginal/cervical lacerations r/t macrosomia, multifetal, precipitous labor - Hematomas (Swelling, discoloration, tenderness and bulging area just under the skin) - Ruptured uterus Manifestations - Slow, steady flow of blood of unclotted blood - Lochia rubra that continues into the fourth day following birth - firm uterus Intervention - surgical removal of hematoma if > 3cm

Answer 78

Factors - Preeclampsia - Stillbirths - Coagulation disorders (DIC) Manifestations - Oozing from IV sites - abnormal clotting (Nosebleeds, Petechiae, Bleeding gums) - Hypotension (shock)

Answer 79

Early PP Hemorrhage Timing: 1st 24 hr (esp. 1st hr) Manifestation: soak 1 pad q15 mins Cause: Uterine atony, Distended bladder, high or unrepaired laceration or vaginal hematoma Late PP Hemorrhage Timing: >24H after the birth, but < 6 weeks Manifestation: soak 1 pad q1 hr Cause: subinvolution r/t Retained products of conception, Endometriosis

Answer 80

- Tachycardia - Tachypnea - Skin- cool, pale, clammy - Dizziness, nausea - Anxiety, “air hunger” r/t hemorrhage - Urine output decreases - Hypotension (late sign) - blood loss (> 500 mL in vaginal, > 1000 mL in cesarean) - decreased Hct by 10% since admission or 2% in first 48 hrs pp

Answer 81

- more fatigued than the usual pp woman - discharged w/ iron supplements OR increase iron foods((leafy green vegetables, beans, red meat, poultry, iron-fortified cereal, breads, pasta, dried fruits (raisins)) - increase fluids

Answer 82

- support lower uterine segment above symphysis pubis (prevents uterine inversion) - use circular motion - reassess after 5-10 minutes of massage

Answer 83

Timing: day 1-3 Consistency - bright red bleeding that diminishes in amount and pales in color (scant in C-section) - May have fleshy odor (similar to menstrual blood) - small clots - increased amount w/ standing or breastfeeding

Answer 84

Timing: Day 4-10 Consistency - pink-brown - scant amount and fleshy odor - increased amount w/ physical activity

Answer 85

Timing: Day 10-14 Consistency - creamy white or yellow discharge of mucus and leukocytes - scant amount and fleshy odor

Answer 86

Scant: < 1 inch or only on tissue when whipped Light: < 4 inches Moderate: < 6 inches Heavy: saturated within 1 hour Excessively heavy: soaked in 15 minutes

Answer 87

- void 300 mL q2- 4 hours - use bathroom/bedpan (Foley catheter may be needed if suspect retention (< 100cc/hr. or < 300cc/void) - Administer analgesics if dysuria - Use peppermint oil b-c vapors relax urinary sphincter - Drink minimum of 10 glasses per day (2L of water/day) - Do pelvic floor muscle training to improve continence, sexual function and prevent prolapse. - Cotton underwear - Nutrition (increase urine acidity w/ cranberry juice, apricots, plums)

Answer 88

Delayed due to: (for 2 weeks PP) - Fluid losses and dehydration - Decreased GI motility r/t pain meds, decreased physical activity - Perineal discomfort r/t hemorrhoids, lacerations, episiotomy GI changes - constipation - NV r/t labor - No BM expected for 2-3 days - increased appetite is normal - weight loss (11-12 lb immediately, 5-8 lb r/t diuresis)

Answer 89

- Administer stool softeners or Dulcolax (stimulant if needed) - Ambulate to increase GI motility and decrease risk of gas pains. - Drink 10 glasses (3000 mL) of fluid per day esp. water and prune juice - Increase fiber and roughage in diet (fruits, vegetables, whole grains, legumes)

Answer 90

- Position patient laterally and lift buttock to expose anal area (note # and size of hemorrhoids, thrombosis) - Topical anesthetics for discomfort - Topical steroids, sitz baths, cold compresses to reduce edema - Stool softeners (Colace)

Answer 91

- Wash hands - Cleanse front to back with peri-bottle lavage, blot dry - Change peri pads when soiled- monitor for odor as a sign of infection - Vulvar ice packs and cold sitz bath (1st 24 hrs) for edema - Warm sitz bath after 24hrs to promote circulation and healing. - analgesics (ibuprofen and acetaminophen) prn for discomfort - Topical anesthetics (Anesthetic creams/sprays, Witch hazel compresses, Hemorrhoidal creams) for discomfort - Tighten gluteal muscles as pt sits then relax them after she sits to cushion perineum and increase comfort.

Answer 92

Redness, Edema, Ecchymosis, Drainage, Approximation of edges of episiotomy or laceration Levels 1st Degree: Vaginal Membranes 2nd Degree: Vaginal Membranes + Fascia 3rd Degree: Vaginal Membranes + Fascia + Anal Sphincter 4th Degree: Vaginal Membranes + Fascia + Anal Sphincter + Anal Canal Types of epistiomies - Midline = heals quicker and less pain than mediolateral - Mediolateral = incision at 45-degree angle to perineum

Answer 93

- teenage mothers - social support - experienced mothers vs new mother - pregnancy readiness - pregnancy and birth experience (baby in NICU, pain, CNS depressantS) - cultural beliefs - infant characteristics (appearance, temperament)

Answer 94

- Commitment, attachment, and preparation for infant during pregnancy - Acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the early weeks after birth. - Moving toward a new normal during the first 4 months - Achievement of a maternal identity around 4 months

Answer 95

- Last 24-48 hrs - Focused on self (not infant)- personal comfort, rest, food important - Decision making difficult so dependent on others for help in care - Re-lives delivery experience

Answer 96

- Lasts from 2 days-1 wk - Dependence -> independence (decision making) - shift from pregnancy role to maternal role - Increased energy level - need reassurance about ability to meet infant needs - great time for teaching

Answer 97

- From 1 week onward - See self as separate from infant - Give up fantasy delivery and baby - may have feelings of grief, guilt, Depression - Readjustment – giving up previous role

Answer 98

Timing - first few days – 2 weeks due to hormones, fatigue, role stress for most women - peak day 5-10 S/s - Able to care for baby - mild mood swings (emotional lability, feeling sad, anxious, or overwhelmed) - crying spells - insomnia and anorexia - fatigue or restlessness Management - assess at 1-2 week check up - encourage rest

Answer 99

- Sleep/appetite disturbances (insomnia, hypersomnia, weight gain, weight loss) - emotional distress (Anxiety, fear, panic, guilt) - inability to concentrate - Despondent (feeling down/depressed or hopeless; loneliness, isolation) - Thoughts of harming baby or self - unable to safely care for infant

Answer 100

Timing - Lasts longer than 2 weeks within 12 months PP Management - assess in pediatric setting or at 2-week PP visit - for mild PPD, Psychotherapy - for moderate PPD, Psychotherapy AND antidepressants - for severe PPD or suicidal ideation, Psychotherapy, Antidepressants, Intense psychiatric care, ECT

Answer 101

- LGB > heterosexual - Hx of depression or anxiety during or prior to pregnancy - Inadequate social support (poor quality relationship w/ partner OR mother; life stressors) - young age - unintended pregnancy (ambivalent about having a baby) - family history - birth or pregnancy different from plan (cesarean, emergency w/ mother or newborn, NICU baby) - Abuse: IPV, history of childhood sexual abuse - Low SES

Answer 102

- may resume sexual activity at 2-4 weeks - 3 criteria for resuming: Bleeding is slowed/stopped; No discomfort experienced; Pt is ready psychologically - Episiotomy/lacerations typically healed after 2 weeks - Hormonal contraception safely initiated after 3 weeks (LARCs can be placed in immediate PP) - Use of lubricant advised due to vaginal dryness

Answer 103

- Soaking a pad/hr, presence of egg sized clots; return of rubra - Fever: Temp > 100.4 lasting 24hrs or longer in first 10 days - Mastitis: Redness, swelling, lump in breast - Cystitis: dysuria, frequency, urgency - Thrombophlebitis: Pain in calf; PE if SOB or chest pain - Endometritis: Foul smelling vaginal D/C, pelvic pain - Postpartum Depression: thoughts of hurting yourself or someone else - Preeclampsia: severe headache, seizures, blurry vision, epigastric or abdominal pain, facial swelling

Answer 104

- Maternal suicide - Hemorrhage (most common after suicide) - infection - hypertensive disorders - VTE

Answer 105

Definition: death of a woman during pregnancy or within one year of pregnancy (CDC) not related to accidental or incidental causes. Statistics - more likely in AA women due to discrimination and bias - 50% preventable - 50 % after discharge

Answer 106

- Nonjudgmental care - Resource management (transportation) - Patient-centered care (tailor to patient’s lifestyle)

Answer 107

Use: uterotonic for PP hemorrhage prevention or treatment Side effects: hypertension, NV, headache Contraindications: BP > 140/90

Answer 108

Use: uterotonic for PP hemorrhage (prostaglandin) Side effects: NVD, fever, increased BP, headache Contraindications: asthma

Answer 109

- Call for help - Massage uterus (if firm, find source) - Empty bladder (foley) - IV access (increase rate of maintenance fluids and maintain blood products) - Add Uterotonic Medications: oxytocin, methergine, hemabate to IV (given in 4 hrs PP) - O2 (10-12 L via nonrebreather) - lateral position. elevate extremities for venous return - notify provider (bimanual compression, balloon tamponade, pack w/ gauze) - Weigh blood-soaked peripad (1g = 1mL)

Answer 110

S/s - fever, malaise - Tachycardia - subinvolution - excessive fundal tenderness - return of lochia rubra - foul-smelling lochia Management - clindamycin and gentamicin OR ampicillin until afebrile for 24-48 (IV if severe)

Answer 111

- Cloudy urine - labs: hematuria, bacteriuria - frequency, urgency - dysuria and suprapubic pain - costovertebral angle tenderness with Pyelo - Small, frequent voiding of <150 mL per voiding

Answer 112

- History of c/s - PROM - Invasive procedures (Frequent cervical exams, Internal fetal monitoring, amnioinfusion, episiotomy/lacerations,) - Preexisting pelvic infection (bacterial vaginosis, UTI, cervicitis - Poor nutrition (obesity, malnutrition) - DM - Epidural (urinary retention) - Anemia ( < 11) - prolonged labor

Answer 113

- prevention with hand washing and aseptic technique - Monitor vitals and temperature (tachycardia, fever) q4h or q2h if elevated temp - Increase fluids and promote nutrition (2L fluids; 1800-2000 calories if lactating, 1500 cal if nonlactating) - Administer antibiotics and analgesics - Monitor for worsening of signs and symptoms: Bleeding, drainage, pain

Answer 114

inflammation/infection of breast which locally obstructs flow of milk usually at 3-4 weeks OR 3-6 months of breastfeeding Cause: due to bacteria entering nipple cracks r/t improper infant latch S/s - Red, warm lump in breast with radiating erythema - cracked, blistered, reddened nipples - Fever, malaise, chills - body and headache Complication: abscess formation

Answer 115

Management - continue to breastfeed b-c infection in breast tissue not milk - Nipple care (moist heat for circulation) - antibiotics (cephalexin, dicloxacillin) for 10-14 days Prevention - Fully empty both breasts during breastfeeding - Massage breast during breastfeeding esp. tender areas and under armpit - Wear larger bra. - Use correct latch-on and removal, air-dry nipples, and multiple breastfeeding positions to decrease nipple irritation and tissue breakdown. - Hand hygiene prior to feeding - Avoid missing feedings.

Exam 3 Flashcards

(139 cards)