Week 13 Review for Last Maternity Exam (1) PDF

1. Postpartum physiological assessments and nursing care and High-risk PP care a. Assessments and frequency i. 15 minutes x 1 hour, 30 minutes x 1 hour, 4 hours x 22 hours, then q shift. ii. Assessing for hemorrhage (complications DIC, AFE, PE), HELLP/Eclampsia...

1. Postpartum physiological assessments and nursing care and High-risk PP care a. Assessments and frequency i. 15 minutes x 1 hour, 30 minutes x 1 hour, 4 hours x 22 hours, then q shift. ii. Assessing for hemorrhage (complications DIC, AFE, PE), HELLP/Eclampsia 1. Vital signs a. Temp. BP. HR. RR. SpO2. Pain 2. Lochia a. Color, amount, odor 3. Fundus a. Void, supine for best assessment b. Height (U), Tone (firm, boggy), Location (midline, displaced) iii. Shift head-to-toe add-ons 1. BUBBLE-HE 2. REEDA (posterior) b. Critical findings i. Purulent discharge (infection) 1. Odor 2. Fever, tachycardia, tachypnea, pain ii. Bleeding >500 ml vaginal birth (>1000 ml c/s) 1. Quantitative blood loss (weigh/measure) 2. Hypotension, tachycardia, tachypnea, dizziness, pale, cool, clammy iii. Boggy and deviated fundus (s/s of hemorrhage) 1. Void 2. Massage until firm 3. Oxytocin (IV or IM) 4. Reassess q 30 minutes iv. Preeclampsia/eclampsia, HELLP (DIC) 1. Hypertension (above 160/100) 2. HA, nausea, AMS/Sz, blurred vision, RUQ pain, edema 3. Bleeding (everywhere), petechiae, purpura v. Sudden drop in O2 Sat 1. Anaphylaxis 2. PE 3. Hypotension (hemorrhage) c. Hemorrhage i. Fundus should be firm and midline, involution ii. Primary PPH (Early) (1st 24 hours) 1. Uterine atony- urinary retention a. Fundus is boggy, elevated, deviated b. Void (straight cath for PVR) (Foley for retention) 2. Uterus normal (midline, firm) a. Laceration (red bleeding with normal fundus) b. Hematoma (normal fundus, ecchymosis, swelling, severe pain) iii. Secondary PPH (Late) (after 24 hours) 1. Retained placental fragments/tissue a. Subinvolution, rubra/odor/changes in color, metritis (septic, DIC) d. Infection i. Breast (mastitis with/without abscess) (3-4 weeks post delivery) 1. Redness (localized), pain, warmth, fever, HA, flu-like s/s 2. Encourage BF, chin toward red area, pumping afterwards a. Only dump Breast-milk with pus present 3. Plugged duct (warm showers/compresses, massage toward nipple) 4. Keep area clean, dry, hand-washing. 5. Keflex (antibiotics), Tylenol for pain. ii. Metritis (>24 hours) 1. Retained tissue, stillborn, intercourse/objects, STI, wiping 2. Odor, pain, fever, s/s of infection iii. Incision/laceration (wound) 1. C/section, lacerations, improper wound care, DM, immunocompromised, obesity, chronic hypertension iv. UTI 1. Anesthesia, Foley, Straight cath, operative vaginal birth, urinary retention, peri/hygiene, urethral trauma, dehydration, pads too long 2. Pyelonephritis (kidney)- flank pain e. Other complications i. DIC ii. Anaphylaxis iii. VTE/DVT and PE f. Psychological disorders i. Baby blues (postpartum blues) 1. First 2 weeks, few days 2. ABLE to perform all ADLs ii. Postpartum Depression (MDD) 1. First year 2. UNABLE to perform ADLs a. Changes in sleep, appetite, weight, self-care 3. Psychosis may be present, self-harm, baby-harm 4. Immediate appointment or ED iii. Postpartum psychosis (manic Bipolar-I) 1. Early as day 3 2. UNABLE to perform ADLs 3. SI/HI, never leave with baby unattended, supervise all interactions and care 4. ADMITTED iv. Paternal postnatal depression (low Testosterone) 1. Provider visit, therapy or replacement/meds g. Discharge teaching i. Normal resolution of pregnancy vs abnormal findings 1. Lochia (rubra, alba, serosa) 2. Involution and afterpains (increase with multiparity, breast feeding, oxytocin) 3. RhoGAM for Rh- mom to prevent problems with future pregnancies ii. Recognition of s/s of PP depression iii. PPH remains a leading cause of morbidity and mortality  iv. Infection v. Preeclampsia, HELLP, Eclamptic seizures vi. Diet, exercise, sleep/activity, smoking cessation vii. Resuming sexual activity, contraception (ovulation prior to menses) 2. Transition to parenthood a. Teaching i. Needs are met prior to teaching (pain, position, toilet, etc) ii. Evaluate for understanding iii. Infant communication b. Support i. Observe and promote bonding ii. Communication of expectations c. Loss i. Promoting successful grief (DABDA) ii. Support, avoid retraumatization 3. The neonate a. Transition to extrauterine life i. Normal assessment 1. Tone: flexed 2. Head: fontanels flat, symmetrical, eyes/ears, nares patent a. Cephalohematomas (injury from vacuum) b. Caput Succedaneum (serous crosses sutures) 3. Chest: crackles (amniotic fluid) a. Resp 30-60, patterned- count for full minute b. Apical pulse 110-160, slightly irregular (respirations) 4. Abdomen: soft, round, belly breathing, cord (AVA) 5. Genitalia: a. Female- spotting vaginal discharge, swollen labia b. Male- palpate both testes, swelling scrotum 6. Back: skin is closed (no sacral dimples or tufts of hair) 7. Limbs: Gluteal folds symmetrical, no clicks hip movement, symmetrical movement of all extremities. a. Acrocyanosis- mottling or cyanosis on extremities 8. Skin: Core should be normal coloration a. Document: lanugo and vernix, slate gray patches (hyperpigmentation), birth marks, injuries, vascular spots 9. Reflexes a. Observe for any missing or asymmetrical findings ii. Critical findings 1. Jaundice (1st 24 hours- pathologic) 2. Pallor, dusky, cyanosis 3. Hypotonia, Seizure 4. Fontanel bulging, sunken. Clefts. Low set ears 5. See-saw or paradoxical breathing, Tachycardia/Tachypnea, Bradycardia/Bradypnea, Resp distress (grunting), accessory muscle use  6. Distension, decreased bowel sounds. No meconium >48 hours, No urine >24 hours. Bright green or bloody stool. 7. Vital signs: a. Temp under 36.5/97.7 or over 100.4 b. HR under 100 (under 60 start compressions) or over 180 c. RR under 30, apnea for more than 15 seconds, or over 60 d. SpO2 under 94 (initially 65%, rapidly increases to 90s in about 10 minutes) 8. Glucose 15 seconds is critical iv. RDS/BPD 1. RDS: tachypnea with retractions 2. BPD: Preterm (not fully matured lungs/surfactant) a. Ventilation, O2 lead to fibrosis and alveolar collapse 3. Oscillatory ventilation is decreasing rates of BPD 4. Bronchodilators, steroids, diuretics – prevent FVO/HF v. PDA 1. Heart failure (increases blood flow through pulmonary vessels) pulmonary HTN 2. NPO/fluid restrictions (IV maintenance rate only), diuretics – treat FVO/HF vi. ROP 1. Retinal detachment, related O2 vii. Infections/Sepsis 1. GBS- Group B strep- meningitis or pneumonia- sepsis a. Vaginal culture 35-37 weeks b. IV maternal antibiotics prior to delivery c. Hospitalization: Abx: 24 hours i. Not tested, or no abx: 48 hours d. Monitor for s/s of infection (fever, tachypnea, tachycardia, hypoglycemia)  2. Erythromycin eyes- blindness viii. Jaundice 1. 24 hours- pathological jaundice – neuro damage 2. Treat: Bili lights (cover eyes), Feed ix. PKU 1. Neuro damage 2. Screen: heel stick (2-5 days of feeding), check prior to d/c return for follow up. x. NEC 1. Necrotic bowel- surgically removed (NG/OG tube, NPO), IV fluids, Abx. 2. Risk: premature. Reduce risk: breast milk (pump, tube feed in nursery) xi. Meconium aspiration 1. Risk: Stress (hypoxic event) and postdates 2. Presentation: amniotic fluid is green at time of rupture 3. Aspiration syndrome: low APGAR scores, floppy, poor air entry 4. Treatment: SUCTION, assist provider with tracheal intubation with suction, prepare for resuscitation (BVM, O2, Suction, warmer) c. Teaching i. Abusive head trauma 1. Put baby down in safe place and walk away (10 minutes) cry it out. 2. Talk: friend, family, Parent stress line ii. Circumcision and cord care 1. Circumcision: infection, cleaning, pain, bleeding, swelling (urinating) 2. Cord: avoid direct pressure, cleaning iii. SIDS prevention 1. Crib safety, back to sleep, no swaddling for sleep (sleep sacs) 2. Avoid overheating, exposure to smoke/tobacco 3. Breastfeeding, pacifier iv. Bathing, diapering 1. Spot cleaning, never leave alone near water, dry well after bathing 2. Cleaning with diaper changes, fold to avoid cord v. Feeding 1. Breast feeding a. Engorgement, nipple care, pumping and storage 2. Bottle feeding a. Preparation and storage 4. Women’s health a. LGBTQIA i. Ask, do not assume. Use correct pronouns and body part terms. Support and provide safety. Alter care as needed to avoid re-traumatization b. STIs i. Barrier devices do not protect against all STIs. Can transmit without symptoms. ii. Gonorrhea and chlamydia- PID, infertility 1. Reportable DOH, contact tracing iii. HPV- warts/cancer 1. Warts are flesh colored, cauliflower growths 2. Vaccine, slow growing (PAP smear) c. Vaginitis i. Bacterial- Fishy odor, grey discharge, Metronidazole (Flagyl) ii. Yeast- Candidiasis, cottage cheese, sour, itching, Miconazole (Monistat) d. Cancer screening i. Cervical- PAP 1. No intercourse 48 hours prior ii. Breast- Mammogram- annual provider breast exam 1. No deodorant, powders, or lotions iii. Endometrial- bleeding after menopause, endometrial biopsy 1. No prep needed e. Surgery i. Fibroids 1. Removal of benign tumors can increase fertility ii. Hysterectomy 1. Major abdominal surgery 2. Hemorrhage, Infection (wound, UTI), DVT, internal injuries, paralytic ileus 3. NPO (gag), Ambulate (after anesthesia wears off) 4. Remove foley once they can ambulate, monitor for first void iii. Fistulas 1. Pain, constipation, stay with patient for first bowel movement 2. Education about avoiding constipation f. PCOS i. Complications (diseases/disorders can result) ii. Fertility (metformin, clomid, exercise/weight loss) g. Menopause i. Perimenopausal- symptoms ii. Menopause 12 months with no menses iii. Postmenopausal- increased risk of stroke, heart attack, osteoporosis (DEXA) h. IPV i. Increased with pregnancy. Preterm birth. Low birth weight. Neonatal Death.