Flashcards in Test 3 Blueprint (2) Deck (51):
What should the nurse expect when palpating the breasts of a PP client?
PP day 1 or 2: soft, colostrum
PP day 3 or 4: firm from milk coming in
When is engorgement expected?
3-5 days when milk comes in
What is colostrum?
Clear, yellowish fluid available for the first 2-3 days PP
What is the nutritive value of colostrum?
High in antibodies & protein
Low in fat & carbs
Colostrum: High protein facilitates binding of _____.
Colostrum: Laxative action encourages passage of _____.
Colostrum: Establishes normal _____ _____ flora in infant's gut.
Colostrum: Contains ____ ____ that provides passive immunity.
Interventions to treat breast engorgement:
- Apply COOL compresses BETWEEN feedings
- Apply WARM compresses/take WARM shower BEFORE feeding
Nutritive sucking is associated with increased production of ____.
(the more nutritive sucking, the more milk production)
Hormone for milk PRODUCTION
Hormone for milk LET DOWN
(Remember the Ps & Os)
PROduction = PROlactin
Let down = Oxytocin (Oxytocin lets milk OUT)
What are the parameters of elevated temp indicative of infection in the PP client?
- After 24, PP temp of 100.4 or higher
- Lasts for 2 consecutive days during first 10 days PP
Interventions for perineal edema in the first 24 hrs:
- Ice pack (reduces edema, provides analgesia)
- Meds (acetaminophen, NSAID, opioid)
- Topical anesthetics (Americaine spray, Dermoplast, Tuck's Pads...witch hazel) for hemorrhoids
What's the difference between a laceration & an episiotomy?
Laceration = tear
Episiotomy = cut made by physician
Classify the degrees of lacerations/episiotomies:
1st Degree: superficial vaginal mucosa or skin of perineum
2nd Degree: deeper tissues including muscles of perineum
3rd Degree: same as 2nd but extends to the anal sphincter
4th Degree: extends through anal sphincter into the rectal mucosa
Periurethral: laceration in the area of the urinary urethra (never intentionally cut)
Interventions for perineal healing & comfort AFTER first 24 hrs:
-Sitz bath at 100-104 or cooler at least 2x day
-Analgesia (acetaminophen, NSAID, opioid)
How many calories should the LACTATING PP client consume over the recommended pregnancy calories?
(This is 450-500 kcal more than the non-lactating moms)
Education to help prevent mastitis:
- wash hands before breast feeding
- keep breasts clean, change breast pads often
- let nipples air dry
- teach proper infant positioning/latching on techniques; release suction before removing baby from breast
- completely empty breasts at each feeding to prevent milk stasis = medium for bacterial growth
What are major indicators of UTI in a prenatal or PP client?
frequency with overflow
urgency...esp urgency but with incomplete emptying
What causes frequent urination/diaphoresis PP?
Fluid shift as uteroplacental circulation is eliminated --> increasing circulating volume (ABOUT 3RD DAY)
Mobilization of fluid...eliminated by diuresis & diaphoresis
Output may > 3000 mL/day
When would rubella vaccination be administered to non-immune PP client?
after birth & then 1 month later
What is isoimmunity?
Mom's Rh (-) blood builds antibodies to baby's Rh(+) blood. Next baby, if Rh (+) can be negatively effected
Behaviors of the "TAKING IN" phase:
- 1st 1-2 days PP
- Introspective and preoccupied with own needs rather than new baby
- Passive/dependent behavior
- Excited & talkative
- Touches & explores infant
- Needs to verbalize L&D experience
Behaviors of the "TAKING HOLD" phase:
- 2nd-3rd day PP, lasts 10 days to several weeks
- Moves toward more independent behavior
- Desires to take charge
- More receptive to teaching --> learning readiness
Behaviors of the "LETTING GO" phase:
- 10 days to several weeks after Taking Hold phase
- Achieves realistic independent role
- Establishes norms for self and family
- Mothering functions established
- Resumption of relationship with partner
- Resumption of sexual activity
- Family system enters new phase of development
The best time for teaching PP clients is in the ____ ____ phase of adjustment.
Symptoms of PP blues:
- transient depression usually 2nd-3rd day PP or withing 2 wks
- mood swings, anger, tearfulness, feeling let down, anorexia, insomnia
- emotionally labile, cries for no reason
- usually resolves spontaneously
Symptoms of PP depression:
Same as blues but do no not go away or are more severe
What is a hematoma?
Blood filled vesicle that develops in the perineal area following delivery. Can be very painful and doesn't respond to pain meds. May feel like "sitting on a softball".
Characteristics of EARLY PP hemorrhage:
- critical time is 1 hr past delivery
- bright red blood
- may be related to lacerations
- indicated by continuous trickle of blood in spite of contracted uterus
Characteristics of LATE PP hemorrhage:
- 24 hrs or more after delivery
- dark red blood
- caused by retained fragments of placenta in the uterus
- infection is another cause
- why we check that the placenta is delivered intact
How often are assessments made in recovery?
q15 min for 1st hr
q30 min for 2nd hr
q4 hr x 4
then every 8 hrs
Major causes of early PP hemorrhage:
tears & lacerations
Major causes of late PP hemorrhage:
retained placental fragments or infection
What would be the first intervention you would perform to manage PP hemorrhage?
S/S of PP shock:
- persistent significant bleeding - peri pad is soaked within 15 min
- lightheaded, sees stars
- anxiousness, signs of air hunger
- skin looks gray or ashen
- skin feels cool & clammy
- increased pulse
- decreased BP
When is the best time for maternal-infant bonding?
What infant would miss the initial bonding time?
high risk babies taken immediately to NICU
What is the ANTERIOR fontanel shaped like?
5 cm, diamond shaped
What is the POSTERIOR fontanel shaped like?
smaller than anterior, triangle shape
Sunken fontanel =
Bulging fontanel =
How much vitamin K is given to a newborn?
Do you aspirate?
What size needle is used to administer Vit K?
What muscle is it injected in?
5/8 in, TB syringe
Why is vit K given to babies after birth?
When is it given?
Prevents hemorrhagic disorders
Newborn liver can't synthesize Vit K
Not produced in GI tract until day 8
(Given within 1 hr after birth)
What needs to be done before given a vit K shot to a baby of an HIV positive mom?
Bathe first, cleanse site with alcohol
Prevents introduction of HIV pathogens into the break in the skin
Erythromycin ointment administered into baby's eyes after birth...why?
prevents blindness that could be caused by
- Neisseria gonorrhoeae
What should be done with the unused portion of a bottle of formula?
throw it out...risk of bacterial contamination
What are the S/S of an infant with jaundice?
- yellowish tint to skin, sclera, & mucous membranes
- starts at the head & progresses down the thorax, abdomen, and extremities
Why does jaundice occur?
- Excess breakdown of RBCs
- Liver immaturity --> not enough of enzyme glucornyl transferase
- Poor sucking ability --> doesn't consume enough food to introduce intestinal flora so blilirubin not conjugated to direct form that can be excreted
- Cold stress
What days would you see physiologic jaundice? Pathologic jaundice?
Physiologic = AFTER 24 hr of age
Pathologic = BEFORE 24 hr of age or persistent after day 7