Test 3 Blueprint (1) Flashcards
(51 cards)
How frequently should the nurse perform focused PP assessments after delivery?
1st Hour: q15 min
2nd Hour: q30 min if stable
Then every hour for 4 hr
Then every 4-8 hr until discharge
What are the classifications & length of discharge after birth?
Rubra (1-3 days)
Serosa (4-10 days)
Alba (11-6 wks)
List the levels and values of lochia rubra.
Scant ( 10 cm)
Heavy (pad saturated within 2 hr)
Excessive blood loss (pad saturated in 15 min or less, pooling of blood under buttocks)
What is the consistency of each lochia?
Rubra: bright red, bloody, fleshy odor, small clots
Serosa: pinkish brown, serosanguineous consistency
Alba: yellowish, white creamy color, fleshy odor
What does REEDA stand for?
Redness Edema Ecchymosis Drainage Approximation
What are the steps with uterine involution?
(Remember 1 & 2)
- 1-2 cm below the umbilicus immediately after birth
- Within 12 hrs rises to umbilicus or slightly above, then…
- Descends 1-2 cm/day
- Nonpalpable by 2 weeks
Contractions are initiated and/or maintained by the hormone _____ from the _____ _____ gland.
(Remember “OPP”)
oxytocin
posterior pituitary
What 2 meds are administered in PP to maintain a contracted uterus?
Pitocin & Methergine (methylergonovine)
What assessment should be made before administering Methergine?
Check BP –> hold med if greater than 140/90 or greater
Afterpains are more common in ____ & ____ clients.
multigravidas & breastfeeding
When should pain meds/NSAIDS be given to relieve afterpains?
before breastfeeding
What is the importance of the process of exfoliation?
Tissue regeneration at site of implantation without scar tissue
What should we be concerned about if lochia reverts back to an earlier stage (ex/ serosa then back to rubra)?
1) hemorrhage from retained placental fragments
2) infection
What is uterine atony?
Uterine muscles fail to contract sufficiently after birth; feels soft and boggy
Atonic uterus leads to…
postpartum hemorrhage
What is the most common reason for PP hemorrhage?
atonic uterus
When you weigh a peri pad, 1 g equals…
1 mL
What is the priority intervention when a PP client is bleeding excessively or if they pass a clot?
- check consistency and location of fundus
- check for distended bladder
- massage the uterus
What is the #1 reason for a boggy uterus?
full bladder
How do you decide if the uterus is boggy b/c bladder is full or for some other reason?
If the fundus is pushed up above where it should be for the day postpartum; or if the fundus is to the left/right
What symptoms would you assess for if the pt’s peri pad is soaked within 1 hours?
- lightheaded
- nauseated
- acts anxious, c/o air hunger
- ashen or grayish skin
- skin coll & clammy
- increased HR
- decreased BP
What labs are drawn on mom 12-24 hrs post delivery?
- H&H (esp. c-sec)
- urinalysis, culture, sensitivity
- Rubella titer
- Rh status
What do we teach a pt receiving the rubella vaccine?
- if not immune, admin vaccine after birth then again 1 month later
- avoid pregnancy 1 month after each dose
- may develop rash
- safe for breastfeeding
- allergy to duck eggs may cause hypersensitivity
What test checks for Rh antibodies in mom’s blood?
Indirect Coombs test
