NUR314 Exam 4 PDF

NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 goes through constant changes very quickly as it pro- gresses toward a pre-pregnancy state; Mother and family go through psychological and social cha...

NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 goes through constant changes very quickly as it pro- gresses toward a pre-pregnancy state; Mother and family go through psychological and social changes. 44. Infant safety ID bracelets (baby wears 2, both partners wear 1); Abduc- tion: infant security alarm tied to infant security tags, re- lease to personnel correctly identified only (all personnel must wear correctly identifying badges), be aware of and report all suspicious activity. 45. Postpartum as- Done every 15 minutes for the first hour, every 30 minutes sessment at second hour, every 4 hours 22-24 hours after deliv- ery; B-breast (engorgement, nipples), U-uterus (boggy or firm, placement - involution), B-bladder (amount of urine, retention), B-bowel (flatus, last BM), L-lochia (color, amount, clots, odor), E-episiotomy (redness, edema, ec- chymosis, discharge, approximation), E-extremities (mo- tor function, DVT), E-emotional status (interaction with family and baby, comfort level, mood swings). 46. Breast changes 1st 24-48 hours (breasts should be soft - colostrum); (postpartum) About 48 hours post-delivery (breasts become full but are non-tender); some degree of engorgement (breasts are full of milk) can be felt by both breastfeeding and non-breastfeeding mothers (swollen, firm, tender, warm; 2-3 days after delivery with non-breastfeeding mothers then hopefully dry up; at time of feeding for breastfeeding mothers). 47. Comfort Good supportive bra / sports bra 24 hours a day until measures breasts become soft; Avoid breast stimulation (don't ex- (non-breastfeed- press milk; apply ice to breasts - 15 mins at a time every ing moms) hour, cold gel packs or cold cabbage leaves inside bras); Avoid application of heat (shower with water to back); Mild analgesia for pain (Ibuprofen - Advil, Motrin). 48. Comfort mea- Frequent feedings using proper techniques; Warm com- sures (breast- presses to breasts / massaging breasts prior to feedings feeding moms) to help with "let down"; Pump / manually express if infant not feeding; Ice / analgesia after feedings for comfort; 9 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 Supportive (non-constrictive) bra; Warm showers to front; Keep nipples lubricates (milk, organic products, lanolin); Avoid using soap on nipples; OTC analgesia for "after- pains". 49. Mastitis Infection of the breasts; Bacteria enters cracks in nipples; Milk stasis (build up of milk in breast tissue often r/t pro- longed times between feedings, excessive stress, and/or fatigue, plugged milk ducts); Continue feeding or "pump and dump" per provider orders; Moist heat to affected breast; Antibiotics, rest, analgesia, hydration, nutrition. 50. Mastitis (S/S) Flu-like symptoms, redness, tenderness, pain (unilateral- ly). 51. Uterine changes At or near the umbilicus in the first 1-12 hours; descends (postpartum) about 1 cm each day; after about 10-14 days, unable to palpate (returns to true pelvis); normal finding (midline, firm, contracted) 52. Fundal palpation Inform and explain; empty bladder; supine position (with (postpartum) legs flat or slightly flexed); Place one hand at the sym- physis pubis and the other at the umbilicus, pressing in- ward and downward to locate fundus; Gently press down (assess tone, location, position) - should be firm and midline, if deviated bladder may not be completely empty; If boggy, massage with palm of hand; watch lochia during massage. 53. Soft uterus Soft and midline, massage until firm (reassess in 5 min- utes); Soft and deviated to the side, have patient void and reassess (midline and soft - massage, remains deviated and soft - may need an in and out cath to empty blad- der); Remains soft after massaging (oxytocin per facility / provider protocol, notify provider) - if no response to oxytocin further assessment and intervention by provider my be necessary. 54. Urinary changes Transient stress incontinence (may last up to 6 weeks (postpartum) or longer with each delivery; multiparity, perineal trauma, 10 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 macrosomia, prolonged second stage, excessive push- ing); Bladder distention / decreased bladder tone (rapid filling of the bladder with maternal diuresis; incomplete emptying, inability to void - epidural analgesia, oxytocin administration, urethral/perineal edema, bladder trauma); Cystitis (UTI related to above) 55. Constipation Increase fluid intake and daily fiber (fruits, vegetables, (postpartum) prune juice, whole grain foods); stool softeners (no strain- ing - docusate); don't ignore the urge to go; ambulate early and often. 56. Hemorrhoids Avoid long periods of sitting / side-lying is best; witch hazel (postpartum) pads / proctofoam / sitz bath; sit gently, straight up, on hard surface. 57. Appetite (post- Regular diet (if not n/v), snacks between meals; Breast- partum) feeding (extra 500-1000 calories/day). 58. Weight loss Close to pre-pregnancy weight by 6 months pp. (postpartum) 59. Gastrointestinal Early voiding (within 4 hours after delivery); measure all changes voids (300 mL within normal limits with first void; may (postpartum continue up to 72 hours); If void is < 150 mL palpate for nursing actions) bladder distention (uterine atony, fundus above umbilicus and deviated to the right, increased bleeding, firmness in suprapubic area); assess for retention using bladder scanner; try non-invasive measures; catheterize as need- ed per protocol; educate on UTI prevention and s/s; in- struct on Kegel exercises. 60. Endometrial Rubra (deep red; day 1-3); Serosa (pink-brown; day 4-10); changes Alba (white to yellow-white; day 11-up to 8 weeks); WNL (postpartum) for all stages (fleshy odor, clots smaller than the size of a half dollar or small egg). 61. Peripad (post- Scant: blood only on tissue when wiped or less than partum) 1-inch stain; Light: less than 4-inch stain; Moderate: less than 6-inch stain; Heavy: saturated within 1 hour; Ex- 11 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 cessive: excessive bleeding when nursing and first time standing after sitting/laying. 62. Endometrial Fundal assessment and massage (primary pp hemor- changes (patient rhage first 24 hours after birth; late pp hemorrhage most teaching) common 7-14 days after birth (can be up to 12 weeks); normal stages for lochia progression (call for increase in bleeding, return to former stage, foul odor, large clots); Infection prevention (change peripad frequently with each void or as needed - from front to back; UTI prevention) 63. After-pains Typically last for 48-72 hours after delivery; intermittent (postpartum) uterine contractions felt during uterine involution; mild in first time moms; more pronounced in miltiparas, if uterine distention occurred and in breastfeeding moms 64. After-pain relief Walking soon after birth; breathing / relaxation tech- niques; heat to lower abdomen; prevent bladder from becoming full; mild analgesics (ibuprofen and naprox- en); Mild opioids (hydrocodone-acetaminophen, oxy- codone-acetaminophen, no Tylenol or cough meds with acetaminophen while taking). 65. Vaginal and per- Vagina and labia (swelling, bruising, lacerations); hem- ineal changes orrhoids; episiotomy/laceration; hematomas (vaginal, vul- (postpartum) var, perineal, rectal). 66. Laceration (as- Redness (mild okay, no deep red streaking); Edema (no sessment) shiny edema); Ecchymosis (no deep purple, no buldg- ing); Discharge/drainage (none); Approximation (no de- hiscence). 67. Laceration (com- Stool softeners; Ice packs to perineum first 24 hours fort measures) (every hour for 10-15 minutes); warm sitz bath after first 24 hours (2-3 times a day for 20 minutes and after bowel movements - perfusion); side-lying positions in bed; pil- low beneath one hip when sitting; prescribed oral anal- gesics (Ibuprofen, Norco); peri-bottle rinse with warm water after each void; topical anesthetic (witch hazel 12 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 pads-Tucks-cooling, anesthetic sprays-numb, anti-inflam- matory creams-Proctofoam-decr. inflammation). 68. Sitz bath Fill basin and bag; use room temperature water; may use betadine if prescribed by healthcare provider; opening of tubing to back of toilet; release clamp after sitting; 3-4 times a days (and after BM), 20 min each time; if in tub 4-6 in of water, drain before bath. 69. Cardiovascular Cardiac output increases after delivery sometimes caus- changes ing slight bradycardia (never below 50 bpm; returns to (postpartum) normal within 10 days); Volume balances out slowly (fluids shift from extracellular to intravascular spaces; anemia may be present for up to 8-weeks); WBC levels increase after delivery secondary to stress- no infection (may be >30000 / usually return to normal within 1 week); Clot- ting factors that increase with pregnancy return to nor- mal within 3-4 weeks (control hemorrhage but increase risk of clots); Decreased vascular resistance in pelvis (increased profusion to tissues and increase in venous return to heart, orthostatic hypotension is common dur- ing first week); Blood pressure should compare with first trimester (slightly lower than pre-pregnancy levels - lower may be indication of pp hemorrhage); Elevated levels may indicate pp pre-eclampsia (systolic increase of > 30 mmHg and/or diastolic increase of > 15 mmHg, especially in the presence of other symptoms - HAs, edema, visual disturbances.) 70. Normal WBCs 5,000-10,000 71. Cardiovascular Assess VS with fundal assessments (BP should be nor- changes mal - assess lying, sitting, standing for orthostatic hy- (nursing potension, pulse may be normal or slightly bradycardic); interventions) Assist with ambulation first 24 hours; Have ammonia cap- sule in the room or readily available especially first time up; Assess H&H levels routinely during stay and prior to d/c home (HGB: 11-12 until about 4-6 weeks pp, if anemia occurs - iron supplement is standard); Assess for DVTs (LE pain, redness, swelling, warmth, hard area; 13 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 compare pulses bilaterally; measure calf circumference if DVT suspected); Fluid loss and hormonal changes may cause "pp chills" (1-2 hours; normal temp - warm blanket / adjust room temp; elevated temp: notify provider and as- sess for s/s infection); Education (change positions slowly, especially first week; early and frequent ambulation; don't cross legs or ankles; compression stockings if history of clots). 72. Emotional status Bonding (love, care, and concern that are unique to the (postpartum) parents relationship with their baby; begins with con- firmation of pregnancy and continues throughout early childhood); Attachment (slow process that builds and deepens over time); Assessment and education (identify knowledge and skills deficit; communicate / listen; help parents to understand and recognize their strengths; offer information to help with decision-making; provide oppor- tunities to progress from dependence to independence with confidence). 73. Learning to par- Watching what others do; remembering how we were ent raised by our own parents; reading books; watching videos / reading pamphlets; classes taken prior to deliv- ery; join support groups. 74. Role of becom- Often begins as a young girl; fostered during pregnancy ing a mother (may be complicated by maternal risks or fetal complica- tions); enhanced with support from others; healthy expec- tations (positive feelings, nurturing behaviors, protective instincts, increasing expectations). 75. Rubin's 3 phas- Taking-in, taking-hold, letting-go. es of maternal adaptation 76. Taking-in phase First 1-2 days postpartum / dependent phase; Mother: focuses on personal needs (sleep, food), allows others to make decisions and take care of her, relives her labor experience, claims the baby ("he has my nose"); Nurse: encourages mother to rest, short teaching sessions may 14 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 be offered but should only include immediate personal needs. 77. Taking-hold Day 3 to day 10-14; Mother: less dependent with deci- phase sion-making but may still need reassurance, more inde- pendent with self care, focus is turned toward the infant, moves from "being pregnant" to "being a mother", may show signs of the blues; Nurse: best time to teach mother about infant and pp care. 78. Letting-go phase Day 10-14 to 6 weeks pp; Mother: independent with self and infant care, may grieve over separation of the baby from her body, fully assumes new role (new mother, moth- er to more than one child), begins to place more emphasis on her relationship with her partner as well as the rest of the family, pp depression may set in, decides to return to work or stay home. 79. Role of becom- Typically does not begin until pregnancy or after birth; ing a father men usually think about themselves fathering older chil- dren; considers importance of being present in their child's life and about helping them to preform functionally in society; feel extreme pressure to care for their family physically and financially; nurse should be sure to include the father in infant teaching. 80. Delayed bonding Complications that prevent mother and baby from being / attachment close after delivery; extreme maternal/paternal fatigue r/t lack of assistance; maternal pain following birth and during the pp period; immaturity; stress r/t financial con- cerns, lack of support; pregnancy was unplanned; single parenting. 81. Positive bonding Hold baby close; refer to baby by name; prefer baby to be in room; ask questions / appear interested in infant care; respond to infant's needs 82. Negative bond- Call infant "it" / refuse to use name; avoid eye contact (with ing no cultural connotation); do not appear interested in infant 15 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 care or about learning how to care for infant; prefer infant to remain in nursery / others to care for infant. 83. Mother (infant First stage: uses fingertips only to explore infant, fearful contact) of harming baby; Second stage: begins to use hand to explore infant, awkward but less fearful; Third stage: holds infant in arms and pulls close to body, quickly becomes more confident, holds infant face-to-face and talks with low pitched voice. 84. Father (infant Engrossment; Father's absorption, preoccupation, and contact) interest in infant shortly after birth; Often stimulated by witnessing the birth (seeing infant as attractive / beautiful, strong desire to touch or hold the infant, is not aware of any imperfections, focuses all attention on the baby when they are in the room, able to easily identify the baby based on features, feeling of elation (strong happiness), feels extreme pride. 85. Positive infant Stages of maternal touch are observed; Father: spends contact time looking at and touching the infant, is happy with how the infant looks. 86. Negative infant Little interest is shown in the infant; negative comments contact are made about the infant; little time is spent with the infant / holding the infant. 87. Culturally com- Hot-cold balance (offer warm beverages / foods instead petent care of cold, may prefer to not have ice pack to perineum, may prefer to keep room warm); Maternal confinement (moth- er and baby remain isolated for 40 days to help in recovery from childbirth, focus is on mom rather than baby, visitors may be restricted); Gender of the baby (female baby may be less desirable than male). 88. Beliefs about Revered for its symbolism of life, spirit, and individuality placenta (buried in specific areas to bind the child to their ancestral land and people; has its own spirit, washed and buried by the husband in a secret and shady place to prevent the mother or baby from becoming sick / dying); Nursing 16 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 mother should boil the placenta, make a broth, then drink it to improve her milk. 89. Respiratory WNL (respirations 12-20; O2 sats > 95%); Assess for changes pulmonary edema (oxytocin, mag sulfate, preeclampsia); Cesarean delivery (IS, TCDB, ambulation; assess for at- electasis, pneumonia). 90. Changes in im- Temp may rise to 100.4 or slightly higher; this may or may munity (first 24 not indicate infection; anything >101 during this time is hours) likely an infection (should be reported regardless of other symptoms). 91. Changes in im- Temp should return to normal (any temp >100.4 should munity (after first be promptly assessed for s/s of infection); PP infection is 24 hours) typically dx after 2 temps of 100.4 or higher have been obtained at least 6 hrs apart. 92. Changes in im- Offer Rubella vaccine if non-immune (MMR; rubella titer munity (vaccina- < 1:8--- 1:9 is non-immune); May also offer influenza, tions) varicella, TDaP, and Hepatitis B (if needed); RhoGam to Rh- moms who gave birth to Rh+ infant (w/in 72 hours). 93. Changes in im- Temp elevated but 101 F at any time (hydrate, notify provider and nursery); Edu- cate on vaccines and offer vaccine information statement; Signed consent or refusal; Administer vaccines as indi- cated and accepted; RhoGam if needed. 94. Endocrine Estrogen levels decrease after delivery and begin in- changes (all) creasing after 1 week; Progesterone levels undetectable at about 3 days PP, production is resumed with first men- strual cycle. 95. Endocrine Prolactin levels progressively decrease over first 3 weeks; changes menses begins at about 6-8 weeks PP; ovulation returns (non-breastfeed- at around 10 weeks. ing) 17 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 96. Endocrine Prolactin levels remain increased and menses is sup- changes pressed with breastfeeding; ovulation and menstruation (breastfeeding) returns around 17 weeks PP (if breastfeeding exclusively) 97. Endocrine Insulin dependent women (insulin requirements usually changes decrease for the first few days and then gradually begin (nursing actions) to increase); Educate on use of contraception with re- sumption of sexual activity (ovulation may return prior to menstruation, breastfeeding is not a good form of birth control); Increased diaphoresis especially at night (de- creased estrogen, elimination of increased fluids, assess for increase in temperature if diaphoresis is present). 98. Diastasis recti Reduced abdominal tone; soft, flabby appearance; im- proved with time and exercise 99. Muscular and Reassure that appearance of abdomen is normal (ed- nervous system ucate on exercise); ice/heat to muscles as needed; as- changes (nurs- sess for return of sensation with epidural (avoid ambula- ing actions) tion until sensation returns); assess HA's (preeclampsia - unchanging, visual disturbance; spinal - worse when upright); encourage rest and sleep/reassure that fatigue is normal (nap when baby is napping; cluster care when possible). 100. Nutrition (PP Lactating women: increase caloric and fluid intake daily, self-care) what you eat and drink baby eats and drinks; All women: increased fiber, increased iron with anemia (green leafy vegetables, beans, red meat, poultry). 101. Smoking (PP Increased risk for clots, cessation is advised. self-care) 18 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 102. Sexual inter- Avoid for 6 weeks after delivery; Safe: lochia stopped, course (PP perineum healed, emotionally/physically ready. self-care) 103. Activity (PP Exercise helps with weight loss and improves mood; light self-care) exercise (walking) 2-3 times per week, increase over time as tolerated and as ok'd by provider. 104. Rest when Avoid unnecessary activities; accept assistance. baby rests (PP self-care) 105. Contraception Offer information on different options; encourage discus- (PP self-care) sion with provider. 106. Elimination (PP Empty bladder q4-6 hours and PRN; avoid constipation. self-care) 107. Perineal hygiene Cleanse perineal area after each void / BM and before ap- (PP self-care) plying new peripad using fresh warm water; gently spray water using peri-bottle so that it runs from front to back; pat dry using toilet paper or cotton wipes (front-to-back); hand hygiene before and after peri-care; peripads only, no tampons. 108. When to noti- Lochia (excessive bleeding, clots, foul odor, change in fy provider (post- color); 2 temps > 100.4F; increased abdominal / pelvic partum) pain; s/s UTI; s/s preeclampsia; s/s DVT and PE; thoughts of self-harm or harm to baby, unable to sleep, unable to care for infant. 109. Reducing risk Be aware of risk factors (prolonged labor, forceps/vacuum (PP complica- delivery); Early recognition for early intervention (acute tions) change in vitals, frequent fundal assessment); Ambulate early (prevent DVTs and PEs); Urinate often (prevent bladder distention causes uterine atony / hemorrhage, urinary retention causes cystitis); Hand hygiene. 110. Postpartum hem- Blood loss: >500mL - vaginal delivery, >1000mL - cesare- orrhage an delivery ; 10% drop in Hgb and/or Hct from admission 19 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 to after birth; blood loss requiring a blood transfusion after childbirth (anemia or unstable VS); no universal measures exist for direct measurement of bleeding so it is important for the nurse to assess for risk factors and to monitor the patient closely. 111. PPH (primary Tone: uterine atony (> 75% of the time); Tissue (retained causes) placental fragments); Trauma (genital laceration); Throm- bin disorders (DIC and clotting disorders). 112. Primary PPH Early PPH that occurs within 24 hours after childbirth; 80% uterine atony; 20% lacerations, uterine inversion or rupture. 113. Secondary PPH Late PPH that occurs 24 hours to up to 12 weeks after childbirth (most often occurs in the first 2-weeks); most are the result of infection, subinvolution, retained placen- tal fragments, clotting disorders. 114. 30-40% Because maternal blood volume is increased by almost 50% during pregnancy, the typical s/s of hemorrhage may not appear in a PP woman until 1800 - 2100 mL of blood has been lost ( _____ of total volume). 115. Mean arterial First indicator of PP heme; Average arterial pressure pressure (MAP) in the vessels during one cardiac cycle; Indicates how well organs are being perfused; Normal: 70-100 mm Hg; Formula: 2(diastolic BP) + systolic BP/3. 116. Uterine atony Uterine muscles fail to contract around the blood vessels (tone) at the area of placental separation, preventing hemosta- sis, and increasing bleeding; Uterus may remain soft and relaxed (boggy) even after massage; Dark red bleeding filled with clots; VS changes usually not seen until almost 50% of blood has been lost. 117. Oxytocin (uter- Pitocin; first line treatment for PPH; stimulates uterus ine atony) to contract (IM or IVPB); assess for hypervolemia and uterine hyperstimulation. 20 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 118. Methyler- Methergine; manages PPH caused by uterine atony or gonovine subinvolution (IM); may cause elevated BP, palpitations, (uterine atony) and chest pains (monitor BP and HR); not for women with cardiac h/o or HTN. 119. Misoprostol Cytotec; Off-label use for PP hemorrhage when oxytocin's (uterine atony) don't work; given per rectum; affects prostaglandins; SE: n/v, diarrhea. 120. Carboprost (uter- Hemabate; Acts as a prostaglandin to increase contrac- ine atony) tions (IM); used more often than Cytotec. 121. Intrauterine bal- Catheter with a 300 mL balloon is placed through the loon tamponade vagina and into the uterus. The balloon is filled with (uterine atony) enough saline to place pressure against the vessels at the placental attachment site so that bleeding stops. 122. Bimanual uterine Internal and external uterine massage together; per- compression formed by placing one hand in the vagina and pushing against the body of the uterus while the other hand com- presses the fundus externally. 123. PPH (treatment) IV fluids (isotonic - NS or LR); blood products (PRBCs; Platelets, FFP, cryoprecipitate for massive hemorrhage); O2 administration (10-12 L via facemask); bimanual uter- ine compression; intrauterine balloon tamponade; surgi- cal interventions (if all interventions fail to stop the bleed- ing; D&C and/or hysterectomy). 124. PPH (nursing ac- Assess fundus and lochia / VS / patient behavior; If PPH tions) is identified and uterine atony is believed to be the cause: Immediately begin continual / vigorous fundal massage while supporting lower uterus (*priority - may try to have baby latch), call for help / notify provider, have a second 21 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 person initiate IV access (if not available) with 18 gauge cath or larger, obtain labs (H&H, PT, PTT, fibrinogen, type and cross) / begin oxytocin, insert Foley if bladder dis- tended, elevate legs, O2 via face mask, monitor bleeding and VS as interventions are initiated. 125. PPH (goals) Primary is prevention and recognition (bladder empty, risk factors, fundal massage, VS); If recognized priority is to stop bleeding. 126. PPH (remember) Always turn patient to the side or have her lift buttocks to assess for pooling of blood beneath her; When pre- forming fundal massage (support lower part of uterus while massaging to prevent uterine inversion); Do not over massage (quit when firm; can cause over-tiring of the uterine muscle which can result in uterine atony). 127. Laceration May be cervical, perineal, vaginal, labial (internal - for- ceps, precipitous, dystocia); Assessment (uterus firm and midline, steady stream or small trickle of bright red blood without clots); Nursing (assess for risk factors, monitor VS and blood loss, notify provider of findings); May be repaired under epidural anesthesia (must be repaired to stop bleeding). 128. Hematoma Blood collects in the tissues of the vulva, perineum, rectum, or vagina when blood vessels are injured dur- ing delivery; bleeding is not usually visible; Assessment (vaginal/perineal pain that cannot be controlled, feeling of fullness / pressure in the vaginal/perineal area, per- ineal/vulvar swelling, ecchymosis, tenderness; May be monitored (small) or excised and evacuated (large); Risk factors same as laceration. 129. Hematoma (nurs- Apply ice first 24 hours to perineal area (preventative); As- ing actions) sess for s/s (extreme pain, vaginal or rectal fullness, uter- ine atony may be present if hematoma is large enough); Administer pain meds; Notify provider of findings; Assess for s/s of hypovolemic shock. 22 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 130. Uterine subinvo- Failure of the uterus to return to normal size after delivery; lution Assessment (fundus is higher than expected, back pain may be present, lochia does not progress through normal stages or returns to the rubra stage after leaving); Thera- peutic management (retained placental fragments - D&C, fibroids - PO methergine, endometriosis - Abx.) 131. Retained placen- Small pieces of the placenta remain attached to the tal fragments uterus after expulsion of the placenta; increased risk with manual removal of the placenta (recommended if placenta has not been expelled within 30 minutes after delivery of the baby); Assessment (sudden, heavy, dark red bleeding with clots - usually after 1 week pp, uterine subinvolution, uterus is soft and relaxed - not contracting); Therapeutic management (D&C and Abx.) 132. Acute bleeding Assess for cause and intervene necessary; Monitor (VS, (nursing actions) I&O, LOC, fundal tone and location, amount of bleeding); Lay the patient supine with legs elevated 15-30 degrees; Encourage frequent voiding (catheterize if necessary); IV fluids and blood products as needed; Prepare to assist with provider interventions; Reassure the patient and fam- ily. 133. After the bleed- Fundal assessments q 30 minutes - 1 hour for first 4 ing is over (nurs- hours after; Educate patient (fundal massage, s/s, when ing actions) to call provider); Increase oral / IV fluids; Remind about the importance of frequent voiding; Assist with ambu- lation; Monitor labs (H&H); Answer questions and offer reassurance. 134. Disseminated In- Small clots are formed in vessels throughout the body travascular Co- at an increasingly fast rate, blocking blood flow to the agulation (DIC) extremities and organs; Formation of these clots is hap- pening so quickly that they begin to use up all of the body's clotting factors, so that the patient begins to bleed profusely. 135. DIC (goals) Hemodynamic stability with increased tissue and organ perfusion; Assess labs (decreased platelets and fibrino- 23 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 gen, increased D-dimer, prolonged PT/PTT); IV fluids; PRBCs, platelets, FFP, cryoprecipitate; O2. 136. DVT Clot that forms deep in a vein (usually LE); Unilateral ede- ma, redness, warmth, sudden pain; Diagnosis: doppler, D-dimer (negative - low risk; positive - needs further as- sessment). 137. PE Clot that breaks away from the wall of a vein and travels to the lungs; Sudden onset SOB / chest pain, tachypnea, tachycardia; Diagnosis: spiral CT (done to see if any clots have moved to the lungs) and Ventilation/perfusion (V/Q) scan (measures how well air and blood move through the vessels). 138. Venous Obesity, HTN, smoking, infection/sepsis, use of oral con- thromboem- traceptives. bolism (risk factors) 139. Venous Prevention: early and frequent ambulation, compression thromboem- hose and prophylactic anticoagulation for women with a bolism positive history; Treatment: heparin IV converted to he- (management) parin subQ, warfarin PO, enoxaparin subQ; Education: medication use, frequent ambulation / avoid prolonged sit- ting, never massage the area, avoid constrictive clothing / pressure behind knees, remove stockings several times a day. 140. Endometritis Infection of the uterine lining that generally begins at the placental attachment site and spreads; Assessment: temp >101F usually within first 24-48 hours, lower abdom- inal pain / uterine tenderness, tachycardia, uterine tender- ness, suprapubic pain, subinvolution, flu-like symptoms, heavy lochia with foul odor (usually late sign after spread), increase in WBC of more than 30% in a 6 hour period (cannot use this alone). 141. Obtain cultures to determine sensitivity (endometrial and blood, baby will need to be cultured as well); Administer 24 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 Endometritis antibiotics (oral of IV dependent upon severity of illness); (treatment and monitor VS and fundus; have pt maintain semi-fowler nursing actions) position (so infected lochia can drain out); promote good hygiene; encourage ambulation and good nutrition; pro- mote adequate rest/sleep. 142. Cystitis (UTI) Common in PP period secondary to urethral/bladder trauma, frequent catheterizations, decreased bladder tone/epidural anesthesia; assess for s/s of UTI; treat and educate as with any patient prone to UTIs. 143. Mastitis (s/s) Inflammation/infection of the breast tissue; may be r/t inability to fully empty breast of milk (milk stasis) or from bacteria entering through cracked nipples from the infants mouth; Findings: usually unilateral (breasts are red, ten- der, warm to touch, edematous; malaise, fever, chills, pu- rulent nipple drainage may be present); Treatment: culture and abx (usually oral), mother may continue to breastfeed in most cases, warm moist heat (ice after nursing or expressing of milk). 144. Wound infec- Laceration, episiotomy, or cesarean incision; S/S: red- tions ness, purulent drainage, tenderness, poor approximation, fever; Treatment: culture/antibiotics, clean as ordered; Nursing: assess all wounds for REEDA, VS and cultures, encourage nutrition, fluids, and rest 145. Wound care Remove dressing with first shower; clean incision per (C-section) orders; typically will leave open to air; assess staples to ensure they are intact, no redness/drainage; staples usually removed the day of discharge and replaced with steri-strips; discharge teaching: monitor for redness (may streak), purulent drainage, open areas, foul odor; leave steri-strips in place until they start coming off or until follow-up (whichever comes first). 146. PP (follow-up) Vaginal: 6 weeks; Cesarean: 2 weeks then 6 weeks; Vari- able with pregnancy/delivery related complications. 147. 25 / 26  NUR314 Exam 4 Study online at https://quizlet.com/_brlk97 Psychological PP blues (first 2 weeks postpartum, expected / require expectations no medical intervention, mother can safely and effectively (PP) care for herself and the baby); Mother (happy one minute and then suddenly sad, cries easily and without known reason, trouble sleeping/eating, anxious/easily irritated; Goes away within about 10 days without treatment. 148. Postpartum de- Can occur any time within the first 6 months after deliv- pression ery (most common around the 4th week, requires med- ical/psychiatric assistance, mother is unable to care for herself of her baby); Findings: significant weight loss, insomnia/increased sleeping, agitation/irritation/extreme mood swings, inability to concentrate or make decisions, ambivalence toward new baby (neglect/abuse) or overly concerned about harm coming to baby, flat affect, fre- quent crying/depressed/thinks about death, no interest in appearance or usual activities. 149. PP depression Medical: psychiatric counseling, medication (antidepres- (treatment) sants); Nursing: assess for s/s, make patient and part- ner aware, offer resources (support groups, community resources). 150. PP psychosis Rare but extremely serious; can begin within 72 hours and 1 week after delivery; Assessment: complete insom- nia, irrational thoughts and/or behavior/suspicion, mood swings (depression to extreme elation-mania), incoherent speech, extreme agitation, delusions/voices (baby isn't real); Mother and baby are in danger; Treatment: psychi- atric admission and treatment, antidepressants/ antipsy- chotics/ antianxiety. 26 / 26