maternal and newborn Flashcards
post pardum
nclex tip
Ensure the client voids as soon as possible after
delivery and within 8 hours of catheter removal
to prevent bladder distention, which can lead to
excessive bleeding.
nclex tip
Maternal temperature up to 100.4 F (38 C) is
expected for the first 24 hours postpartum. Notify
the HCP for fever >100.4 (38C), tachycardia,
decreased BP, or BP ≥140/90.
BUBBLE-LE = Breasts, Uterus, Bowel,
Bladder, Lochia, Episiotomy, lacerations, or
cesarean incision, Legs, and Emotion:
Reassure client of expected findings.
Intervene and notify HCP of any
unexpected abnormal findings.
Fundus
Fundus should be firm and at midline.
Involution: Within 12 hr after birth, fundus should
be at umbilicus (U). Fundus then descends by ≥1
fingerbreadth per day.
Fundus
Boggy fundus (uterine atony): Uterus not
contracted Bleeding
Displaced fundus (not midline): Indicates a full
bladder
Subinvolution: Fundus fails to descend
properly, indicating retained placenta or
infection.
nclex tip
Notify the HCP for signs of infection, including
foul-smelling vaginal or incisional drainage.
Notify HCP for signs of infection or poor
healing at the incision or perineum: Redness,
Edema, Ecchymosis, Discharge, or edges not
Approximated (REEDA).
nclex tip
Notify HCP for mood swings that last >14 days
after delivery (postpartum depression) and for
signs of ineffective bonding with the newborn,
such as refusing to hold or forcefully handling
the newborn.
nclex tip
If breastfeeding, increase calorie intake by 350-500 kcal/day, and do not rely on breastfeeding for
contraception. If formula feeding, avoid pumping and applying warm water to the chest, as these
stimulate milk production.
nclex tip
Notify the HCP if the client saturates a perineal
pad in <15 min or has blood pooling under the
buttocks.
nclex tip
If fundus is boggy, massage it, and if fundus is
displaced, empty the bladder.
nclex tip
Oxytocin stimulates uterine contractions and is the
first-line treatment to stop PPH.
nclex tip
A gush of blood from the vagina after prolonged
sitting or lying is expected.
nclex tip
Oozing around the VAD site or petechiae
indicates DIC. Draw platelets and clotting times
(PT, PTT) and administer blood products.
Preterm Labor & Delivery
Risk factors: The priority for preventing
spontaneous PTL is to assess and monitor
for risk factors, including infection, uterine
overstretching, or a history of PTL.
Preterm Labor & Delivery
Symptoms: Teach clients with contractions or
backache occurring <37 completed weeks to
stop activity immediately, lie down on their side,
hydrate, and notify HCP after 1 hour if there is no
improvement in PTL symptoms.
Preterm Labor & Delivery
Diagnostics: For clients reporting symptoms of
PTL, prepare the client for a cervical exam to
assess for cervical effacement and dilation and
perform a fetal fibronectin (fFn) test to evaluate
the risk for delivery within 7 days.
Preterm Labor & Delivery
Interventions: If a client experiencing PTL
symptoms is <34 weeks, administer steroids
(betamethasone) to promote fetal lung maturity.
For active PTL, administer tocolytics (terbutaline,
magnesium sulfate, nifedipine, indomethacin) to
slow or stop uterine contractions.
Preterm Labor & Delivery
Preterm newborn care: Preterm newborns need extra sleep for proper growth and development, so
cluster care and minimize stimulation. Preterm newborns have poor suck-swallow-breathing reflexes,
so monitor them for feeding readiness, indicated by alertness and coordinated suck-swallow-breathing.
