Obs Module 5: Postpartum Assessment & Care for the Mother Flashcards by Ally Metke

your pt in the assessment unit presses the call bell & states, “my water just broke” your priority action would be:
a) do a sterile vaginal exam to evaluate process
b) change the linen
c) call the doctor
d) assess the fetal heart rate
e) assess the fluid for COAT
f) collect a sample for testing via nitrazine swab or ferning test

d) assess the fetal heart rate

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your friend is 39wks gestation w her 1st baby. she knows you are taking your NURS330 Obs course & calls you to see if she should go to the hospital. you would tell her to go to the hospital when… (select all that apply)
a) her contractions are 7-10mins apart lasting 45-50secs
b) her contractions are felt in her abdomen
c) her water breaks
d) her contractions are 5 mins apart & last 45-60secs that last for an hr

c) her water breaks
d) her contractions are 5 mins apart & last 45-60secs that last for an hr

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what are the 2 main components of the postpartum period

physiological: body returns toward pre-pregnancy state
- reproductive organs recover
- hormonal shifts occur
psychological: emotional & social adjustments to a new role
- bonding w infant
- mood changes (baby blues, depression, anxiety)

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how long is the recovery time after birth

around 6wks; psychological adjustment may take longer

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main physiologic events in the PP period

Uterus involutes -> gradually shrinks back to pre-pregnancy size
Lochia -> vaginal discharge (rubra, serosa, alba)
Breasts -> begin milk production; engorgement may occur
GI system -> intestines sluggish for a few days, constipation common
Perineum -> may have hemorrhoids, episiotomy, or laceration healing
Ovarian function -> menstruation returns in 6-12wks (non-lactating women); delayed if breastfeeding

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BUBBLEEES

B - Breasts
U - Uterus
B - Bladder
B - Bowels
L - Lochia
E - Episiotomy/perineum
E - Extremities
E - Emotional status
S - Signs

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Breasts - Normal vs abnormal

Normal = soft, filling; nipples intact
abnormal = engorgement, cracked/bleeding nipples, mastitis

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Uterus - Normal vs abnormal

Normal = firm, midline, involutes around 1cm/day
Abnormal = boggy uterus (atony), deviated (full bladder), not descending

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Bladder - Normal vs abnormal

Normal = voiding without difficulty; no distention
Abnormal = urinary retention, dysuria, frequency, incontinence, displacement of uterus

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Bowel - Normal vs abnormal

Normal = active bowel sounds, passing flatus, 1st BM within a few days
Abnormal = absent sounds (ileus), severe constipation, pain w defecation

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Lochia - Normal vs abnormal

Normal = progression: rubra (1-3d) -> serosa (4-10d) -> (alba 10+d); mild odor only
Abnormal = heavy bleeding, clots, foul odor, return to rubra after serosa/alba

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Episiotomy/Perineum - Normal vs abnormal

Normal = edges approximated, minimal edema, healing perineum - no hematoma or hemorrhoids
Abnormal = hematoma, excessive swelling, dehiscence, purulent drainage, severe pain

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extremities - Normal vs abnormal

Normal = no pain, swelling, or redness
Abnormal = unilateral swelling, warmth, calf pain (possible DVT)

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Emotional status - Normal vs abnormal

Normal = engaged, bonding w baby, baby blues <2wks
Abnormal = persistent sadness, hopelessness, lack of bonding, thoughts of harm (PP depression/psychosis)

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Signs - Normal vs abnormal

Normal = Normal VS
Abnormal = Abnormal VS

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what is lactation?

secretion of milk by the breasts

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Stages of breast milk (3 stages)

Colostrum (birth-day 3): liquid gold/thick & yellow (high in antibodies & protein)
Transitional Milk (day 3-7): increased fat, lactose, calories
Mature Milk (after day 7): thin & bluish yellow; Foremilk = watery, high in lactose & protein (quenches thirst); Hindmilk = creamier, higher in fat (satiety & growth)

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what to assess for breastfeeding moms

Nipples - soreness, bruising, blisters, inversion
Breasts - redness, engorgement, filling/softness
Look for mastitis (pain, redness, fever)

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what to assess for breasts for non-breastfeeding moms

assess breast fullness, discomfort
educate on avoiding nipple stimulation and make sure you have a well-fitting supportive bra

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LATCH assessment tool

L - Latch: is the latch deep, wide, sealed
A - Audible Swallow: can you hear swallowing
T - Type of Nipple: erect, inverted, or flat
C - Comfort: is mom pain-free? Any nipple trauma ?
H - Hold: how is baby held (cradle, football, cross-cradle)

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what is involution

uterus contracting & shrinking back to pre-pregnancy state, which begins immediately after birth of baby & placenta
Rapid process -> takes around 6wks to complete

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if you palpate a boggy uterus shifted to the right, what’s your 1st action?

Get them up to pee

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involution is impeded/stopped by…

full bladder (pushes uterus up/right, prevents contraction)
retained placenta or membrane fragments
overdistended uterus (twins, large baby, too much amniotic fluid)
exhausted uterus (too many contractions = tachysystole)
excessive anesthesia or analgesia (uterus too “relaxed”)

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main causes of PPH: the 4 Ts

Tone (atony): 70% -> uterus won’t contract = gush of blood
Trauma: 20% -> lacerations/tears = trickle bleeding
Tissue: 10% -> retained placenta/membranes
Thrombin: <1% -> clotting disorder

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what to document after a fundal assessment

height (relative to umbilicus) firmness (firm, boggy) position (midline or deviated) incision (if c-section) Lochia (color, amount, clots) musculature (note abd tone)

which of the following complications may be indicated by a PP client who has continuous seepage of blood but the uterus is firm & 1cm below the umbilicus a) retained placental fragments b) urinary tract infection c) cervical laceration d) uterine atony

c) cervical laceration

a nurse is assessing a PP client who delivered 2hrs ago. the client reports heavy vaginal bleeding. on palpation, the nurse notes a boggy uterus, located above the umbilicus & deviated to the right. Which is the most likely cause of the client's excessive bleeding? a) retained placental fragments b) urinary tract infection c) cervical laceration d) uterine atony

d) uterine atony

a nurse is assessing a client 2hrs PP. the fundus is palpated as boggy & deviated to the right. Lochia is moderate. Which nursing action is most appropriate? a) notify the healthcare provider immediately b) document the findings as normal in the 1st hrs PP c) assist the client to void, then reassess the fundus d) administer an oxytocic med as prescribed

c) assist the client to void, then reassess the fundus

abnormal lochia (red flags)

foul smell (possible infection) large clots heavy flow (soaking pads quickly) red lochia returns after it already lightened lats >4wks

Rubra (lochia stages)

days 1-3 dark red, bloody, fleshy, non-offensive (earthy) odor than a toonie = abnormal

serosa (lochia stages)

days 3-10 pinkish brown lighter than rubra

alba (lochia stages)

days 10-24, up to 6wks yellowish to white can last several weeks

what to assess for the Episiotomy/Perineum

Hematoma - swelling, bruising, pain Hemorrhoids - present? painful? Healing - episiotomy/tear site (REEDA) Hemorrhage - gush vs trickle

hematoma

trauma to soft tissue during birth (blood collects under tissue)

signs & symptoms of a hematoma

Severe, unrelieved pain (cardinal sign) Swelling Bruising Pressure

possible complication of a hematoma

can hold 250-500mL of blood -> hidden bleeding risk

causes of hemorrhoids

Increased pressure during pregnancy/delivery Pushing in labor Progesterone (relaxes veins) More common if constipated

hemorrhoids

swollen, inflamed veins in the lower rectum or anus

how to avoid hemorrhoids

Eat high fiber foods Stay hydrated Avoid straining Don't lift heavy TAKE pain meds and use stool softeners

episiotomy

surgical cute made to enlarge the vaginal outlet (historically used to shorten 2nd stage of labor)

1st degree tear

skin only

2nd degree tear

skin and muscle (perineal muscle, but not anal sphincter)

3rd degree tear

skin & muscles that extends into the anal sphincter

4th degree tear

extends though rectal mucosa (sphincter = rectal wall)

on completing a fundal assessment, the nurse notes the fundus is situated on the L side. Which of the following actions is appropriate? a) ask the client to empty her bladder b) straight catheterize the mom immediately c) call the MRP for direction d) straight catheterize the mom for half of her uterine volume

a) ask the client to empty her bladder

a nurse is developing a plan of care for a PP woman w a small vulvar hematoma. the nurse includes which specific intervention in the plan during the 1st 12hrs following the delivery? a) assess vital signs every 4hrs b) inform health care provider of assessment findings c) measure fundal height every 4hrs d) prepare an ice pack for application to the area

d) prepare an ice pack for application to the area

you observe that your PP client, who delivered 3hrs ago has saturated 4 peri-pads w bright red blood during the past hr. her VS are stable. you assess her bleeding to be: a) a normal indication of sub-involution b) abnormal, indicating the need to assess the uterine fundus c) normal, requiring no further action at this time d) abnormal, requiring inspection for a hematoma

b) abnormal, indicating the need to assess the uterine fundus

Virchow's Triad for DVT risk

DVT risk increases w: 1. Endothelial injury (e.g., uterine/vascular damage during birth) 2. Hypercoagulability (pregnancy & PP increase clotting tendency) 3. Venous Stasis (immobility, esp after C-section) &Virchow's triad = Injury, Hypercoagulability, & Stasis

signs of a DVT

redness swelling warmth *calf pain when walking (Red flag)

Taking-in stage of Reva Rubins Maternal Role Attachment Theory

(day 1-2 PP) mom is focused on her own needs (rest, food, shower) talks a/b birth story may touch/explore infant but seems self-focused (normal at this stage)

things to watch for in the Taking in stage (Reva Rubins Maternal Role Attachment Theory)

withdrawal flat affect lack of interest in infant (beyond expected self-focus) persistent tearfulness

Taking-Hold stage of Reva Rubins Maternal Role Attachment Theory

(day 2-3 PP) ready to resume control very eager to learn - best time for teaching! may have rapid mood swings actively practicing mothering role

things to watch for in the Taking-Hold stage (Reva Rubins Maternal Role Attachment Theory)

overwhelming anxiety that interferes w care persistent feelings of incompetence despite reassurance irritability, hopelessness, inability to bond w baby *often when PPD 1st becomes noticable

Letting Go stage of Reva Rubins Maternal Role Attachment Theory

(later transition) sees infant as a unique person shares caregiving w others begins integrating new role into long-term identity

things to watch for in the Letting Go stage (Reva Rubins Maternal Role Attachment Theory)

persistent sadness, guilt, or worthlessness ongoing difficulty adjusting to new role relationship strain, social withdrawal disinterest in activities/infant

PP pinks

mild elation/euphoria hrs/days after birth normal but may also be a warning for extremes = psychosis

symptoms of PP Pinks

bursts of happiness boundless energy extreme productivity racing thoughts difficulty concentrating

symptoms of PP Blues

tearfulness, generalized anxiety agitation, mood swings disturbances in appetite & sleep, being overwhelmed/uncertain irritability

what should you expect from a PP mom who is in the 'taking in phase' (select all that apply) a) she may not initiate contact w her infant b) she should ask for a demonstration of how to bath her babe or provide other care to the babe c) she is mainly focused on herself - eating & sleeping d) she will likely be very concerned w her own independence & ability to control her bodily functions

a) she may not initiate contact w her infant c) she is mainly focused on herself - eating & sleeping

important labs in post partum

hematocrit/hemoglobin (blood loss/hemorrhage) WBC (very high = infection) Platelets (esp if preeclampsia, HELLP, hemorrhage) Rh factor/antibody screen (RhoGAM/WhnRho) Blood glucose (if GDM)

Sandy, G4P3 complains of cramps when breastfeeding, you... (T/F) tell her this is normal

true

Sandy, G4P3 complains of cramps when breastfeeding, you... (T/F) offer her pain meds before feeding

true

Sandy, G4P3 complains of cramps when breastfeeding, you... (T/F) tell her to take deep breaths

true

Sandy, G4P3 complains of cramps when breastfeeding, you... (T/F) encourage bottle feeding until pain is over

false

Sandy, G4P3 complains of cramps when breastfeeding, you... (T/F) offer analgesic prior to feed if possible

true

Sandy, G4P3 complains of cramps when breastfeeding, you... (T/F) tell her it is b/c she has heavy bleeding

false

you are reviewing some danger signs in a PP pt w your study buddy. some of these danger signs include... (select all that apply) a) mom has a temp of 38.5 b) mom states that since giving birth she has had a bit of blurry vision almost like she is seeing spots & a headache c) she says the last time she want to the bathroom she noticed some clots & a lot more bleeding then before d) she says the last time she went to the bathroom her calf hurt a little but no change in her flow

*All of Them* a) mom has a temp of 38.5 b) mom states that since giving birth she has had a bit of blurry vision almost like she is seeing spots & a headache c) she says the last time she want to the bathroom she noticed some clots & a lot more bleeding then before d) she says the last time she went to the bathroom her calf hurt a little but no change in her flow

Obs Module 5: Postpartum Assessment & Care for the Mother Flashcards

(67 cards)