NRSG postpartum, newborn, and family

Question 1

Postpartum Period (when, what)

Answer 1

• When: up to 6 wks post birth
• What: When the reproductive track returns to normal

Question 2

4th stage of labor

Answer 2

first hour after delivery

Question 3

What happens during the 4th stage of labor

Answer 3

*Fundal check begins
*Breastfeeding established
*Client adjusting to situation

Question 4

Primipara

Answer 4

Woman who has had one pregnancy that results in a fetus that attained a wt of 500 g or a gestational age of 20 wks whether or not it was born alive

Question 5

Multipara

Answer 5

A woman who has given birth 2 or more times

Question 6

Grand multipara

Answer 6

A woman who has given birth 5 or more times

Question 7

Handover report of a postpartum patient

Answer 7

*Should be face-to-face to ask questions
*ideally in presence of the pt
*includes accurate and complete prenatal hx
*Risk factors
*Delivery and immediate postpartum recovery summary
*Type of anesthesia, QBL, fluid balance, meds received, pain level
*breastfeeding attempts, and success or need for education

Question 8

ISBAR

Answer 8

Identify yourself
Situation
Background
Assessment
Request or recommendation

Question 9

Postpartum shivering (what)

Answer 9

Seen in 25-50% postpartum women after norm deliveries

Question 10

PP shivering (when)

Answer 10

Usually 1-30 min post delivery, lasts 2-60 min

Question 11

PP shivering (tx)

Answer 11

None needed, warm blanket for reassurance

Question 12

Fall risk (how to eval)

Answer 12

*Evaluate musc control after anesthetic (ask pt to raise her knees, lift her feet one at a time, dorsiflex foot, raise her buttocks off bed
*First ambulation should be w/ assistance
*Sit in shower if needed
*Remain seated when holding the baby
Avoid sudden position changes
Check orthostatic vital signs when appropriate

Question 13

Who is a fall risk

Answer 13

*pts who’ve had anesthetics, narcotics, blood loss, BP

Question 14

Maternal Phsyiologic changes (first 2-3 days)

Answer 14

*Afterbirth pains: contractions during breast feeding
-Positive sign of good sucking by baby, since this stimulates release of oxytocin
-Uterus begins the process of shrinking back to size
-Consider giving Ibuprofen at least 30 min b4 next estimated feeding to reduce afterpains
*Postpartum blues: usually during this stage of PP, subsides in 1-2 wks

Question 15

A client has just been transferred to the postpartum unit from labor and delivery.
Which of the following nursing care goals is of highest priority?
1. The client will breastfeed her baby every 2 hours.
2. The client will consume a normal diet.
3. The client will have a moderate lochial flow.
4. The client will ambulate to the bathroom every 2 hours.

Answer 15

3. The client will have a moderate lochial flow.

Question 16

PP interventions (1st hr)

Answer 16

• Assess every 15 min
• VS
• Height, consistency (firm or boggy), location of the fundus: umbilicus, 1 finger-breadth, above or below umbilicus
• Uterus should be at midline. If deviated to the right, likely a full bladder
  -Fundus should be at the midline, if deviated to right, likely a full bladder
  -Amount of lochia (scant, moderate, heavy)

Question 17

Maternal physiologic changes: Cardio

Answer 17

*Increased circulating blood vol. in immediate PP period
* “Auto-transfusion” of blood that circulated in the uterine muscle during preg
* 60-80% rise in cardiac output for 1-2 hr following delivery

Question 18

Maternal Physiologic Changes: Hematologic

Answer 18

Hematocrit may initially drop due to blood loss associated with delivery but stats to rise again as plasma vol decreases due to diuresis and hemoconcentration

Question 19

A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following?
1. Weight of the uterine body is significantly reduced.
2. Excess blood volume from pregnancy is circulating in the woman’s periphery.
3. Cervix is fully dilated and the lochia flows freely.
4. Maternal blood pressure drops precipitously once the baby’s head emerges.

Answer 19

2. Excess blood volume from pregnancy is circulating in the woman’s periphery

Question 20

On admission to the labor and delivery unit, a client’s hemoglobin (Hgb) was assessed at 11 g/dL and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal
spontaneous vaginal delivery?
1. Hgb 12.5 g/dL; Hct 37%.
2. Hgb 11 g/dL; Hct 33%.
3. Hgb 10.5 g/dL; Hct 31%.
4. Hgb 9 g/dL; Hct 27%

Answer 20

3. Hgb 10.5 g/dL; Hct 31%.
   ▪The nurse would expect these values – a slight decrease in Hgb and Hct

Question 21

Maternal Physiologic Changes: Uterine description

Answer 21

• Rapid decrease in the size of uterus
• Moms who breastfeed may experience a more rapid involution bc of the release of oxytocin

Question 22

Maternal Physiologic Changes: Uterine Involution (assessment)

Answer 22

*Fundal ht decreases about 1 cm/day
*by 10 days PP, uterine cannot be palpated abdominally
*A flaccid fundus indicates uterine atony, and should be massaged until firm
*A tender fundus indicates an infection
*Afterpains decrease in frequency after the first few days

Question 23

Assessment of uterus

Answer 23

*Fundus should feel firm, like grapefruit
*Boggy uterus feels like sponge, difficult to locate
*Observe bleeding during massage
*If pad is saturated or clots are larger than a nickle, or slow steady trickly notify Dr
*Apply fresh pad and reassess hourly

Question 24

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant?
1. Assess client’s fundal height.
2. Teach client how to massage her fundus.
3. Take the client’s vital signs.
4. Document quantity of lochia in the chart

Answer 24

3. Take the client’s vital signs.

Question 25

Lochia changes and names

Answer 25

Rubra: bright red discharge that occurs from day of birth to day 3 -> Serosa: brownish pink discharge that occurs from days 4 to 10 -> Alba: white discharge that occurs from days 11 to 14 *Should not smell foul *May change w/ ambulation

Question 26

Amount of Lochia

Answer 26

*Scant: Less than 2.5 cm (<1 inch) on a menstrual pad in 1 hour *Light: Less than 10 cm (<4 inches) on menstrual pad in 1 hour *Moderate: Less than 15 cm (<6 inches) on menstrual pad in 1 hour *Heavy: Saturated menstrual pad in 1 hour *Excessive: Menstrual pad saturated in 15 minutes

Question 27

Maternal Physiologic Changes: Renal

Answer 27

*Common to have urinary retention as result of elasticity/tone *Might not feel urge to void until she stands up *Diuresis usually begins in fist 12 hrs post birth *Full bladder can displace the uterus and lead to postpartum hemorrhage

Question 28

Maternal Physiologic Changes: Gastro

Answer 28

*Moms feel hungry after birth *Constipation is common with second to third day PP *Hemorrhoids are common

Question 29

Fluid Balance and Electrolytes

Answer 29

▪ Diuresis begins within 12 hours of birth and continues for up to 5 days ▪ Urine output may be 3000ml or more per day! ▪ Additional fluid lost through increased perspiration ▪ Fluid loss greater in patients with preeclampsia or eclampsia ▪ Risk of pulmonary edema and/or unmasking of cardiac disease

Question 30

PP maternal immunizations types

Answer 30

1. Rubella 2. Rhogam 3. Flu 4. T-Dap

Question 31

PP Maternal immunization info

Answer 31

*Indicated in each pregnancy *If T dap is not given during preg, should be given asap *Breastfeeding is not a contraindication to receiving these vaccines

Question 32

Rubella Vacc

Answer 32

*For moms who have not had rubella, or moms who are serologically not immune (titer of less than 1-8) *Live attenuated virus in vacc *Must not be given to preg woman, so PP is a guaranteed, non-preg time *Breastfeeding moms can get vacc

Question 33

RhoGAM

Answer 33

*Given to an Rh- mother prenatally – around 26-28 weeks gestation, even though fetal blood type is unknown *Next does is given within 72 hours after delivery of an Rh+ infant or if the Rh is unknown. *Must be repeated after each subsequent delivery if the baby is Rh+ *RhoGAM 300 mcg is the standard dose

Question 34

PP teaching

Answer 34

*Assess needs and confidence level *Use interactions w/ mom to teach *incorporate "teach back" method *Barriers to learning: fatigue, overstim

Question 35

PP pain management

Answer 35

Use pain scale, ask for description of pain, observe pt

Question 36

After birth pains

Answer 36

*Occurs as a result of contractions of the uterus *More common in multiparas, breast feeding moms, clients w/ oxytocin, clients w/ over-distended uterus during pregnancy

Question 37

Perineal discomfort

Answer 37

*Apply ice packs to perineum during first 24 hrs to reduce swelling *After first 24 hrs, apply warmth by sitz bath or warm tub bath at home

Question 38

Epiostomy

Answer 38

*Instruct pt to administer perineal care after each voiding *Encourage the use of analgesic spray as prescribed

Question 39

Perineal lacerations

Answer 39

*Care like epiostomy *Rectal suppositories and edemas may be contraindicated (to avoid injury to sutures

Question 40

Breast discomfort from engorgment

Answer 40

*Wear support bra at all times *use ice packs between feedings (if not breast feeding: could diminish milk) *Warm soaks or a warm shower *Analgesics

Question 41

PP Consipation

Answer 41

*encourage fluids (2000 mL/day) *Encourage diet high in fiber *Encourage ambulation *Stool softeners, laxatives, enemas, suppositories

Question 42

PP emotional changes

Answer 42

*Acknowledge feelings *Determine availability of fam support *Encourage verbalization of feelings *Monitor newborn for appropriate growth *Assist SO and fam members to discuss feelings *All clients be assessed for depression during preg or PP

Question 43

Pt's w/ chemical dependencies

Answer 43

➢No evidence that withholding analgesics will increase chances of recovery from drug addiction ➢No evidence that providing analgesics will worsen addiction ➢Patients with chemical dependency often require higher loading doses and maintenance doses ➢Consider consulting pain or addiction specialist to help order appropriate doses

Question 44

Maternal Physiological Changes: Breast

Answer 44

*Continues to secrete colostrum for 48-72 hrs post birth *Decrease in estrogen and progesterone levels after birth stimulates increased prolactin levels which promotes milk production *For primiparas: breasts becomes distended w/ milk about third day; earlier for multiparas *Engorgement occurs on approximately 4 days in both breast-feeding and non-breast feeding clients *Breast feeding relieves engorgement

Question 45

Breast feeding and nursing care

Answer 45

*Put bb to mother's breast as soon as they're stable *Stay w/ client each time client curses until client feels secure and confident *Assess LATCH score (Latch achieved by newborn; audible swallowing; types of nipple; comfort of parent; hold or position of baby)

Question 46

Best starts in L&D

Answer 46

*Skin to skin for 1-2 hrs: routine care of mom's chest, minimize separation *Decrease needs for warming *Less hypoglycemia *Uterine contractions allows less blood loss *Immunological components of colostrum protect the infant from bacteria/virus *Increase in the infant's digestive peristalsis *Promotes attachment and bonding

Question 47

Infant sleep states

Answer 47

Deep and light sleep

Question 48

Infant awake states

Answer 48

Quiet, active, crying

Question 49

Best awake state to feed

Answer 49

Quiet state

Question 50

Breast feeding benefits

Answer 50

*Passive immunity *Easily digestible *Brain booster *Low protein content *Convenient, inexpensive

Question 51

Nutrient needs during lactation

Answer 51

*High cal, protein, calcium, zinc, vit B and C *Increase of 200-500 cal more than nonpreg intake recommended

Question 52

Contraindications of breast feeding

Answer 52

Smoking, alcohol, excessive caffeine intake should be avoided *Smoking and drinking should be after breast feeding *Herpes lesions on breasts *Some meds *Restricted diet *HIV positive *Progestin-only birth control pills (not estrogen)

Question 53

Breast feeding positions

Answer 53

*Cradle hold *Cross cradle hold *Lying on side *Football hold *Laid back

Question 54

Breast feeding changes

Answer 54

*During first 24 hrs post birth, little change in breast tissue *Colostrum or early milk, clear yellow fluid, can be expressed from breast. Often leaks toward end of preg (during coitus) place pads in bra *Breast become fuller and heavier as colostrum changes to mature milk (72-96 hrs after birth)

Question 55

Breast feeding challenges

Answer 55

*Sore nipples: confirm correct latch *Low milk supply: nursing more often or pumping will help increase supply *Engorgement: hand express or pump

Question 56

Metabolic changes: Diabetes and breast feeding

Answer 56

*BF may temporarily precipitate hypoglycemia in women w/ insulin dependent diabetes *Mom's with gestational diabetes often have normal glucose levels postpartum

Question 57

Breast care for non breast feeding moms

Answer 57

*Avoid nipple stim *Apply breast binder, wear snug bra, apply ice packs, mild analgesics *Engorgement usually resolves in 24-26 hrs post birth

Question 58

Bottle feeding

Answer 58

*Reliable and nutritionally adequate *Commercial formulas are designed to mimic human milk

Question 59

Formula feeding: Amounts

Answer 59

*24-48 hrs old: 15-30 mL Q 2-3 hr * 1-2 wks: 90-150 mL *Gastro capacity gradually increases *Newborns should be fed on demand, not going longer than 4 hrs between *Wt gain should be monitored

Question 60

Phases of maternal adjustment: Rubin

Answer 60

1. Dependent (taking in) 2. Dependent-independent phase (taking hold) 3. Interdependent (letting go)

Question 61

Dependent phase

Answer 61

▪ First 24-48 hours ▪ Focus is on self and own basic needs, not infant ▪ Relies on others ▪ Is excited and wants to talk about birth experience

Question 62

Dependent-independent

Answer 62

▪ Second to third day to 10 days ▪ Mother begins taking responsibility of self and newborn

Question 63

Interdependent

Answer 63

▪ Focus is on the forward movement of family as a unit with interacting members ▪ Reassertion of relationship with partner—resumption of intimacy and resolution of individual roles

Question 64

Attachment observations in mom: What should we look for

Answer 64

*Seeks newborn face-seeks eye contact *Touch newborn with fingertips first then palms *Cuddling *Acts consistently *Seeks info *Sensitive to changes in newborn *Happy with infants responses *Pleased w/ infant's appearance

Question 65

The nurse is developing a plan of care for a postpartum client during the “taking in” phase. Which of the following should the nurse include in the plan? 1. Teach baby-care skills such as diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills such as pumping.

Answer 65

2. During the taking in phase, clients need to internalize their labor experiences. Discussing the labor process is appropriate for this postpartum phase.

Question 66

The nurse is developing a plan of care for the postpartum client during the “taking hold” phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother

Answer 66

4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.

Question 67

S/S of PP blues

Answer 67

◦ Anxiety ◦ Cries easily for no apparent reason ◦ Emotional labile ◦ Expresses a let-down feeling ◦ Sadness

Question 68

S/S of PP depression

Answer 68

◦ Anxiety ◦ Appetite changes ◦ Crying, sadness ◦ Difficulty concentrating or making decisions ◦ Irritability and agitation ◦ Lack of energy ◦ Less responsive to the infant ◦ Loss of pleasure I normal activities ◦ Suicidal thoughts

Question 69

S/S of PP psychosis

Answer 69

* Break with reality * Confusion * Delirium * Delusions * Hallucinations * Panic * Try to hurt or kill baby

Question 70

Sudden changes

Answer 70

1. Major circulation changes 2. Breathing 3. Maintaining temperature 4. Eating 5. Coping with new stressors

Question 71

Duration of transition periods

Answer 71

6-8 hrs of age * Remember to consider prenatal risk factors, labor, and medications when assessing neonate

Question 72

Transition period

Answer 72

*The placenta is responsible for gas exchange in utero *Majority of healthy newborns take their first breaths spontaneously *Onset of respirations stimulate cardiopulmonary changes that transfer the neonate from fetal to neonatal circulation

Question 73

RN role in transition

Answer 73

Reduce stress, observe, assess, communicate concerns to newborn provider

Question 74

Fetal prep in utero

Answer 74

*Lung fluid decreases near term *Catecholamine surge prior to labor *Catecholamine levels are lower in neonates born via scheduled c-section *Increased surfactant production occurs in last few weeks of pregnancy – helps keep alveoli open after birth

Question 75

Cardio changes when NB takes 1st breath

Answer 75

1. Pulmonary vascular bed dilates which increases blood flow to lungs 2. Pressure in right atrium decreases 3. Pressure in left atrium increases 4. These changes cause foramen ovale, ductus arteriosus, & ductus venous (fetal bypass to the liver) to close

Question 76

Postnatal circulation

Answer 76

Foramen ovale between 2 atria (top heart chambers) closes, normal circ begins *Ductus atrious closes *Right side of heart pumps to the lungs. Left side of heart pumps to the body

Question 77

Patent ductus Arteriosus

Answer 77

* More common in premature babies than in fullterm babies *Temporary

Question 78

Immediate NB care at birth

Answer 78

*Establish respirations *Prevent heat loss through (Conduction, convection, evaporation, radiation)

Question 79

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A. Warming the crib pad B. Closing the doors to the room C. Drying the infant with a warm blanket D. Turning on the overhead radiant warmer

Answer 79

C. Drying the infant with a warm blanket

Question 80

Thermoregulation

Answer 80

Cold stress will interfere with normal transition by increasing oxygen and glucose consumption *Lose body heat quickly: surface body mass ration, small amount of fat insulation

Question 81

Responses (Cues) to Cold Stress

Answer 81

*Vasoconstriction *Increased resp rate *Non-shivering thermogenesis *s/s of hypoglycemia

Question 82

Common NB probs

Answer 82

*Hypothermia *Hypoglycemia *Resp difficulties

Question 83

After birth care

Answer 83

*NB cared for as recovering pt *Critical pt *Observe frequently until stable *Early recognition of abnormal transition

Question 84

Initial care of NB

Answer 84

*Assess *Interventions *Medications *Ensure NB proper ID *General exams: VS body measurements

Question 85

Assessment of NB

Answer 85

*Observe/assist w/ initiation of resps (Do not wait for APGAR) *Monitor nasal flaring, grunting, retractions, abnormal resps *VS *Assist w/ breastfeeding

Question 86

APGAR

Answer 86

*Assess appearance, pulse, grimace, activity, respiration *Assessed at 1 and 5 min *Score 8-10: No intervention needed *Score 4-7: Stimulate- rub bb's back, give o2 *Score 0-3: Full resuscitation

Question 87

Interventions for NB

Answer 87

*Wear non-sterile gloves *Suction mouth first then nose *Dry to stimulate and rub back for cry *Maintain temp: Warm hat, blanket *Keep NB w/mom to facilitate bonding

Question 88

Meds for NB

Answer 88

*Vit K injection: in thigh in first 6hr of birth *Erythromycin eye ointment: Topical antibiotic to prevent eye infection from gonorrhea and chlamydia *Hep B vacc: Given w/i 24 hr, followed up for completion (for HBV infection from infected mom: Hep B vacc and hep B globulin w/i 12 hr of birth)

Question 89

Ensure the NB's proper ID

Answer 89

*Matching ID bracelets *Footprints for NB and finger prints for mom

Question 90

Initial physical

Answer 90

*Keep NB warm *Begin w/ general observations, least disturbing to NB *Ballard scale *VS

Question 91

Ballard scale

Answer 91

used for gestational age assessment r/t physical and neuro criteria

Question 92

NB VS

Answer 92

HR: 110-160 BPM *90-110 is sleeping *up to 180 if crying Resp: 30-60 (assess for full min) Axillary temp: 97.7-99.5 F BP: not usually done unless cardiac issues

Question 93

Body measurements: Head

Answer 93

*Should be 1/4 body length *Bones not fused *Suture: palpable and may overlap *Size of fontanels can vary due to molding *Molding is asymmetrical from pressure in birth canal (disappears about 72 hrs) *Masses from birth trauma

Question 94

Caput succedaneum

Answer 94

edema of soft tissue over bone (crosses over suture line; it subsides in few days) *Common and benign

Question 95

Other body assessment: Penis

Answer 95

Circumcision is not required/expected (parents can choose) *Slight tremors noted in the NB may be a common finding but could also be sign of hypoglycemia, hypocalcemia, or drug with-drawl

Question 96

Infant reflexes

Answer 96

*Rooting: Helps baby find latch *Sucking: Helps baby feed *Moro: response to sudden loss of support (spreading of arms, pulling arms in, crying)

Question 97

Heel stick test

Answer 97

*Screen for Hemoglobinopathies (sickle cell disease), Inborn errors of metabolism, Galatosemia, Severe combined immunodeficiency

Question 98

Other infant tests

Answer 98

*Hearing *Critical Congenital heart disease (CCHD)

Question 99

Hospital length of stay

Answer 99

*Vag: 24-48 hrs *Cesarean: 2-3 days if no complications

Question 100

Follow up care

Answer 100

*Uncomplicated vag delivery: 4-6 wks *Complicated vag or cesarean: 7-14 days *NB visit w/ breast feeding clinic or LIP: 3 days

Question 101

Elimination: Wets

Answer 101

*1 wet on 1st day *6+ by day 6 (up to day six, should be peeing as many times as days old (5 days = 5 wets))

Question 102

Elimination: Stools

Answer 102

*1st 24 hrs: 1-5 mec (dark green and sticky) *Day 2-4: 1-3 dark green transition to loose yellow *Day 6 and beyong: 4+ runny yellow, seedy

Question 103

Discharge care:

Answer 103

*Self care: s/s of complications like fever, heavy bleeding *Sexual activity/contraceptions: 6 wks abstinence, can become preg b4 first period following birth *Prescribed meds *Routine mother and baby checkups