Flashcards in Test 3 Blueprint (1) Deck (51):
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?
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.
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?
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
What is uterine atony?
Uterine muscles fail to contract sufficiently after birth; feels soft and boggy
Atonic uterus leads to...
What is the most common reason for PP hemorrhage?
When you weigh a peri pad, 1 g equals...
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?
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?
- 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
When is Rhogam admin?
With any invasive procedures
Within 72 hrs postpartum (300 mcg IM)
What temperature PP indicates infection?
What can tachycardia indicate?
What is normal HR?
What is normal resp rate?
What do crackles indicate?
possible fluid overload
What is normal for the breasts:
Days 1-2: soft
Days 2-3: filling
Days 3-5: full, soften w/ BF (milk in)
Signs of engorgement:
Firmness, heat, pain
After the first 24 hrs, at what rate should the uterus involute?
~ 1 cm/day
Excessive discomfort of the perineum indicates:
1st 1-2 days
After day 3
1st 1-2 days: hematoma
After day 3: infection
Diuresis begins ____ hrs PP; can void ____ ml/day.
~ 12 hrs PP
What days should a BM be seen PP?
What are normal deep tendon reflexes?
1+ to 2+
What do DTRs >/= 3+ indicate? Why?
The more responsive the DTRs, the closer the pt is to seizure activity
What are signs of uterine infection PP?
- lochia has offensive odor
- lochia reverts to earlier stage color or amount
- lochia persists beyond normal time
Interventions for episiotomy discomfort?
Sitz bath (after 24 hrs)
Witch hazel pads
What causes frequent and perfuse urination and sweating?
Fluid shift, the high fluid volume during pregnancy is no longer needed PP
Marked diuresis, decreased bladder sensitivity, and overdistension of the bladder can lead to...
problems with urinary elimination, esp. UTI
Why is the PP client at risk for thrombus?
- activation of blood clotting factors
What is the best prevention of thrombus formation?
What are symptoms of deep vein thrombosis?
- reddened, warm area over the affected vein
- pain/tenderness on ambulation
What is the usual treatment for DVT?
- bed rest
- moist heat
- anticoagulant (Heparin)
** Don't perform Homan's sign if leg pain, could dislodge clot if there is one.
What is the greatest danger after development of a thrombus (or thrombophlebitis)?
- the thrombus will become a moving clot or embolus
What should be suspected if mom is leaning over trying to get a breath?
What anticoagulant would be given to the lactating client if needed? Why?
Doesn't cross into the breast milk as much
What is the normal lab value for maternal WBCs during PP?
20,000 to 25,000 mm3