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Nursing of Women > SIM Lab Quiz 3 > Flashcards

SIM Lab Quiz 3 Flashcards

(63 cards)

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1
Q

(B)ubble pleb

A

breast

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2
Q

b(U)bble pleb

A

uterus

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3
Q

bu(B)ble pleb

A

bowels

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4
Q

bub(B)le pleb

A

bladder

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5
Q

bubb(L)e pleb

A

lochia

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6
Q

bubble(E) pleb

A

episiotomy

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7
Q

bubble (P)leb

A

pain

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8
Q

bubble p(L)eb

A

legs

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9
Q

bubble pl(E)b

A

emotional state

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10
Q

bubble ple(B)

A

bonding

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11
Q

COCA

A

lochia

color
odor
clots
amount

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12
Q

REEDA

A

episiotomy

redness
edema
ecchymosis
discharge
approximation
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13
Q

APGAR

A 
Appearance: color
Pulse: auscultation
Grimace: tactile stimulation
Activity: movement
Respiration: observation of chest
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14
Q

1st A in APGAR

A 
0 = pale, blue
1 = body pink, blue extremities
2 = completely pink
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15
Q

G in APGAR

A 
0 = none
1 = grimace
2 = cry
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16
Q

P in APGAR

A 
0 = absent
1 = below 100 bpm
2 = over 100 bpm
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17
Q

2nd A in APGAR

A 
0 = flaccid
1 = some extremities flexion
2 = active motion
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18
Q

R in APGAR

A 
0 = absent
1 = slow, irregular 
2 = good cry
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19
Q

APGAR time frame

A

1 min and 5 min

less than 7 at 5 min, obtain scores up to 20 min

monitor every 30 min until stable

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20
Q

apgar score definition

A

rapid assessment of five physiological signs that indicate physiological status of newborn

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21
Q

pagar 0-3

A

severe distress

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22
Q

apgar 4-6

A

moderate difficulty with transition to intrauterine life

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23
Q

apgar 7-10

A

stable status

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24
Q

what does apgar determine

A

rapid, objective, convenient shorthand for reporting status of newborn and response to resuscitation immediately after birth

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25
what does apgar NOT determine
need for resuscitation does not predict long-term neurological outcome of neonate
26
thrombosis definition
blood clot w/in vascular system
27
thrombosis in pregnancy
risk during and 6 wks after birth related to normal physiological changes - increased clotting factors - increased fibrinogen
28
DVT
deep vein thrombosis usually in legs in pregnancy/postpartum
29
embolism
detached DVT that could travel to vital organ
30
risk factors for thrombosis
- normal physiological changes - C-section (5x risk) - endometritis (can spread to vascular system) - decreased mobility - obesity (pressure on vessels) - increased parity
31
assessment findings for thrombosis
- positive Homan's sign - tenderness/heat over affected area - leg pain with walking - swelling in affected leg
32
medical management of thrombosis
- doppler ultrasonography to confirm - compression stockings - coagulation therapy (heparin IV) - antibiotic therapy if related to infection - bed rest with leg elevated
33
nursing actions for thrombosis
- review risk factors - monitor women at high risk - compression stockings - assist with ambulation - report possible signs to provider - administer meds (analgesia anticoagulant)
34
involution
uterus returns to pre-pregnant size, shape, and location; placental site heals - uterine contractions - atrophy of uterine muscle
35
afterpains
moderate to severe cramp-like pains related to uterus working harder to remain contracted and/or to increase oxytocin that is released in response to infant suckling
36
why does uterus need to be contracted post-partally?
reduce risk of hemorrhage - compresses open vessels at placental site and decreases blood loss
37
when to assess uterus
every 15 min w.in 1st hr every 30 min w.in 2nd hr every 4 hrs for next 22 hrs every shift after first 24 hrs
38
boggy uterus
``` not contracted risk of blood loss/hemorrhage massage fundus circular motion reevaluate in 30 min ``` if not responding: oxytocin and call provider
39
expected uterus assessment findings
after birth: at umbilicus 1-2 hrs later: midway btwn umbilicus and pubic symphysis 12 hours later: 1 cm above umbilicus 24 hrs later: 1 cm below umbilicus descends 1 cm/day: descended into pelvis by day 10
40
oxytocin
indication: postpartum control of bleeding action: stimulates uterine smooth muscle contraction adverse rxn with IV: coma, seizues, hypotension, water intoxication route and dose: 10 units in 1 L IV or 10 units IM
41
endometrium
mucus membrane that lines the uterus undergoes regeneration after birth of placenta through necrosis of superficial layer of decidua and regeneration of decidua basalis into endometrial tissue
42
lochia
bloody discharge from uterus that contains sloughed off necrotic tissue
43
endometritis
infection of endometrial tissue
44
scant lochia
less than 1 in on pad
45
light lochia
less than 4 in on pad
46
moderate lochia
less than 6 in on pad
47
heavy lochia
saturated w.in one hr
48
lochia rubra
``` day 1-3 bloody with small clots moderate to scant increase on standing or breastfeeding fleshy odor ```
49
lochia serosa
``` day 4-10 pink or brown scant increase during physical activity fleshy odor ```
50
lochia alba
day 10 yellow to white scant fleshy odor
51
primary breast engorgement
increase in vascular and lymphatic system of breasts precedes initiation of milk production become larger, firm, warm, tender, may be throbbing subsides w/ in 24-48 hrs
52
subsequent breast engorgement
distention of milk glands related to breastfeeding that is relieved by baby suckling or by expressing milk
53
mastitis
infection of breast
54
colostrum
clear, yellowish fluid that precedes milk production high in protein and low in carbs contains immunoglobulins G and A
55
post-partum cardiovascular system
increase in CO related to blood that was previously shunted to uteroplacental unit that is returning to maternal system WBC levels may increase to 25,000/mm within a few hrs after birth and return to normal by 7 days
56
post-partum respiratory system
return of chest wall compliance due to reduction of pressure on diaphragm
57
cystitis
bladder inflammation/infection
58
post-partum endocrine system changes
decreased: estrogen progesterone prolactin estrogen rises after first week
59
nonlactating women
prolactin levels decrease through 3 weeks postpartum menses begin 6-10 wks post birth (1st usually anovulatory - ovulation by 4th cycle)
60
lactating women
prolactin levels increase in response to suckling, which suppresses menses return of menses depends on breastfeeding ovulation suppressed longer than for nonlactating women
61
diaphoresis
profuse sweating, usually at night, in response to decreased estrogen helps excrete excess fluid accumulated during pregnancy
62
diastasis recti abdominis
separation of rectus muscle
63
post-partum gastrointestinal system
constipation hemorrhoids appetite weight loss

Nursing of Women (6 decks)

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