NURS 434 Final Exam Blueprint PDF

NURS 434 Final Exam Blueprint Pad saturation time. Lochia) is usually heaviest in the first 24 hours after delivery and then decreases over time. - Normal lochia is expected to be less than a saturated pad every hour (usually 1 pad every 2-4 hours within the first 24 hours, tapering...

NURS 434 Final Exam Blueprint Pad saturation time. Lochia) is usually heaviest in the first 24 hours after delivery and then decreases over time. - Normal lochia is expected to be less than a saturated pad every hour (usually 1 pad every 2-4 hours within the first 24 hours, tapering off). - If a patient saturates more than one pad in an hour (especially in the first 24 hours postpartum), this is a concern for postpartum hemorrhage (PPH) and should be evaluated immediately. - Postpartum hemorrhage is defined as a blood loss of more than 500 mL after a vaginal delivery or more than 1000 mL after a cesarean delivery. - Menstrual cycles: For regular menstruation, heavy menstrual bleeding (menorrhagia) is indicated when saturation occurs in less than two hours. What is the priority action when a patient saturates peri pad within 15 minutes: Massage the fundus? What is the priority action when a patient saturates peri pad within 1 hour: document the findings A steady trickle of bright red blood from the vagina in the presence of firm suggests what: lacerations of the genital tract. Nursing interventions after an episiotomy A surgical incision made in the perineum during childbirth to enlarge the vaginal opening, nursing interventions focus on promoting healing, managing pain, and preventing infection. - Assess the Episiotomy Site: Regularly inspect the episiotomy for signs of infection such as redness, warmth, swelling, discharge, or a fever. - Perineal Care: Instruct the mother to clean the area after each void or bowel movement. Use mild soap and water and avoid harsh scrubbing. - Proper Wiping Technique: Advise wiping from front to back to avoid transferring bacteria from the rectal area to the incision site. - Drying the Area: After washing, gently pat the area dry with toilet paper or a clean towel. Avoid rubbing, as this can cause irritation. - Encourage Kegel Exercises: Once the initial healing is complete and the woman feels comfortable, pelvic floor exercises (Kegels) can help strengthen the perineal muscles and promote recovery. - Hydration & Nutrition: Encourage adequate fluid intake and a balanced diet to promote healing. High- fiber foods can help prevent constipation, which could stress the perineal area during bowel movements. - Rest and Positioning: Ensure the mother rests as much as possible and avoids positions that put excessive pressure on the perineum (e.g., sitting for long periods without support). Use pillows for extra cushioning if sitting. Indications of epidural recovery One of the most important signs of epidural recovery is the return of normal sensation to the lower body, including the perineal region and legs. - Sensation Level: Nurses often monitor the return of sensation by asking the patient if they feel touch or pressure in different areas of their body, especially the lower limbs. - Motor Recovery: Initially, there may be weakness or paralysis in the lower limbs due to the anesthetic effect. As the epidural wears off, the ability to flex the legs, move the toes, or push against resistance should return. - Assessing Motor Strength: Nurses should assess leg strength (e.g., asking the patient to flex or extend the leg, or push against resistance). - Stable Vital Signs: Epidural anesthesia can sometimes affect blood pressure, causing hypotension (low blood pressure). One of the signs of epidural recovery is the normalization of blood pressure, heart rate, and respiratory rate. - Once the effects of the epidural wear off, patients should be able to feel the urge to urinate and void without difficulty. - Return of Reflexes: The return of reflexes (such as the patellar reflex) is an important indicator of full recovery from the epidural. The reflexes should be assessed by the nurse to ensure that the patient’s motor function has returned to baseline. Interventions to prevent DVT. Risk of DVT and Pulmonary Embolism (PE): The first 3 weeks postpartum have the highest incidence. Symptoms of PE: - Sudden shortness of breath - Chest pain - Tachypnea (rapid breathing) - Hemoptysis (coughing up blood) - Anxiety and apprehension due to difficulty breathing Nursing Care for VTE: - Early mobilization and encouraging leg exercises to reduce the risk. - Monitor for signs of deep vein thrombosis (unilateral calf swelling, redness, pain). - Administer anticoagulants as prescribed. - Evaluate peripheral pulses and perform leg circumference measurements if a DVT is suspected. - Unilateral leg swelling or pain that doesn’t resolve with elevation and rest. - Redness and warmth in one leg or calf could indicate a deep vein thrombosis (DVT). Discharge teaching (maternal danger signs) Excessive Bleeding (Postpartum Hemorrhage) Signs to Watch For: - Soaking through more than one pad per hour or an unusual increase in bleeding. - Large clots (larger than a golf ball). - Bright red bleeding that continues beyond the first few days postpartum (especially after day 7). - Foul-smelling discharge (could indicate infection). Signs of Infection - Fever over 100.4°F (38°C) or chills, which may indicate an infection. - Redness, swelling, warmth, or pain at the incision site (for cesarean or episiotomy). - Tenderness or foul-smelling discharge from the vagina or a wound. - Painful, red, or swollen breasts (could indicate mastitis, especially if breastfeeding). - Severe headache with vision changes, or if you suspect a wound infection (e.g., c-section site). Severe Abdominal Pain - Persistent or worsening abdominal pain that is not relieved by normal postpartum cramping or is much worse than expected. - This can indicate issues such as uterine infection, retained placenta, or a ruptured cyst. Severe Headaches or Vision Changes - A severe headache that does not respond to over-the-counter pain relief. - Blurry vision, flashing lights, or loss of vision. - These could indicate postpartum preeclampsia or other hypertensive disorders. Uterine acne is going to the most common cause of postpartum hemorrhage Lochia stages and durations Stages of Lochia Lochia Rubra (Days 1–3) - Appearance: Bright red, bloody discharge. - Contents: Blood, uterine tissue, placental fragments, and mucus. - Duration: Typically lasts for 1–3 days but can persist up to 5 days in some women. - Normal Changes: This stage is often the heaviest in terms of blood flow. The discharge may contain small clots, especially in the first 1–2 days, but large clots (larger than a golf ball) should be reported to a healthcare provider, as this could indicate excessive bleeding (postpartum hemorrhage). Lochia Serosa (Days 4–10) - Appearance: Pinkish or brownish discharge. - Contents: A mix of blood, mucus, and uterine tissue, but with less blood than in the rubra stage. - Duration: Typically lasts from 4 to 10 days after birth. - Normal Changes: As the uterus begins to heal, the discharge becomes lighter in color and volume. This stage is generally characterized by a decreased amount of discharge, but it can still be noticeable, especially during physical activity or when the woman is upright. At 5 days postpartum a woman should progress to which stage? Lochia Serosa Lochia Alba (Days 10–14, can last up to 6 weeks) - Appearance: White or creamy discharge. - Contents: Mostly mucus, white blood cells, and epithelial cells, with little to no blood. - Duration: This stage typically lasts from 10–14 days, but it can persist up to 6 weeks, especially in women who are breastfeeding. - Normal Changes: Lochia alba is usually minimal in volume and colorless or very pale. It can have a slight odor but should not be foul-smelling. If the discharge becomes foul-smelling or returns to a red color after the lochia alba phase, it could indicate an infection, and a healthcare provider should be contacted. Normal Postpartum adaptations and interventions Uterine Involution: After childbirth, the uterus shrinks back to its pre-pregnancy size. This process, known as uterine involution, usually takes about 6 weeks. It involves the contraction of the uterine muscles and the shedding of the placental site. Fundus (top of the uterus) should descend about 1-2 cm per day after delivery. The uterus may still feel firm and contracted during the first few days post-delivery. Interventions: Fundal Massage: If the uterus is boggy (soft), a nurse may perform gentle fundal massage to help the uterus contract. This reduces the risk of hemorrhage. Lochia (Postpartum Bleeding): Lochia is vaginal discharge consisting of blood, mucus, and tissue from the uterus. It typically lasts for 4-6 weeks. Normal Changes: - Lochia rubra: Red, heavy bleeding for the first 3-4 days. - Lochia serosa: Pink or brownish discharge, continuing for a couple of weeks. - Lochia alba: White or yellow discharge, may last up to 6 weeks. Interventions: - Monitor Bleeding: Heavy bleeding or large clots could be signs of hemorrhage or retained placenta. - Perineal Care: To manage discomfort and reduce infection risk, patients should keep the perineal area clean and dry, using warm water or prescribed cleansers. Perineal and Vaginal Healing: If the woman had a vaginal delivery, the perineum and vagina may experience tearing or episiotomy. Normal Changes: Swelling, bruising, and stitches in the perineal area are common. Interventions: - Ice Packs: For the first 24-48 hours post-delivery to reduce swelling. - Sitz Baths: Warm water baths to promote healing and comfort. - Pain Medications: Mild analgesics (e.g., acetaminophen or ibuprofen) may be prescribed. Cardiovascular and Respiratory Changes: Pregnancy increases blood volume, and after childbirth, the volume decreases as the body adjusts to the absence of the placenta. Normal Changes: Slight tachycardia (fast heart rate) and blood pressure changes may occur in the immediate postpartum period. Interventions: - Monitoring Vital Signs: Postpartum hemorrhage or infections can impact blood pressure and heart rate, so vital signs should be monitored closely. - Encourage Rest and Hydration: Adequate fluids and rest help the body recover and regulate cardiovascular function Postpartum Physiological Changes-5 Kegels Pelvic floor Muscle Weakness What Happens: - During pregnancy, the pelvic floor muscles support the increasing weight of the uterus, but after childbirth, these muscles may become stretched or weakened. - Vaginal delivery, especially with forceps or a vacuum-assisted delivery, can cause further damage to the pelvic floor, leading to incontinence (urinary and fecal) and prolapse. How Kegels Help: - Kegel exercises are designed to strengthen the pelvic floor muscles. This is particularly important in the postpartum period when these muscles are weakened. - Kegels can improve bladder control, prevent prolapse, and enhance vaginal tone. They also help prevent or treat stress incontinence (leaking urine when sneezing, coughing, or laughing). - Strengthening the pelvic floor through Kegels also helps stabilize the pelvis, contributing to better posture and reducing the risk of pelvic organ prolapse. Uterine location by for first 24 hours and by weeks First 24 hours: The uterus is initially at the level of the umbilicus and begins the process of involution, contracting to return to its pre-pregnancy size. - The fundus (top portion of the uterus) will be firm and contracted, helping to reduce blood loss by compressing the blood vessels at the placental site. - The fundus should be about 1–2 cm below the umbilicus immediately after delivery, but it may be higher if the woman had a prolonged labor or excessive amniotic fluid. 1 week postpartum: The uterus has significantly shrunk, and the fundus is typically about halfway between the pubic bone and the umbilicus. - The uterus should still feel firm to touch, though it may feel softer than immediately after birth. If the uterus remains boggy or there is excessive bleeding, it may suggest a complication like retained placenta or infection. 2 weeks postpartum: The uterus continues to shrink, with the fundus being slightly below the umbilicus. - Involution is well underway, with the uterus now at about the size it was at the 16-week gestation stage, though it continues to shrink until it reaches its pre-pregnancy size. 6 weeks postpartum: The uterus has returned to its pre-pregnancy size and position and is no longer palpable in most women. - The fundus may be a bit larger in women who had multiple pregnancies or a larger baby, but by 6 weeks, it should be close to its pre-pregnancy size and position. - The cervix has also returned to its normal post-delivery shape, though it may still be a bit softer than pre-pregnancy. Common Conditions - Uterine Involution Problems: Subinvolution, postpartum hemorrhage, or retained placenta. - Breastfeeding Complications: Mastitis, blocked ducts, and engorgement. - Perineal and Vaginal Trauma: Lacerations, episiotomy, perineal hematomas. - Urinary Issues: Urinary retention, UTIs, stress incontinence. - Gastrointestinal Problems: Constipation, hemorrhoids, diarrhea. - Cardiovascular Risks: Hypertension, DVT, postpartum cardiomyopathy. - Hormonal and Emotional Changes: Postpartum depression, thyroid dysfunction, baby blues. - Skin and Hair Changes: Hair loss, stretch marks, pigmentation changes. Postpartum lab values Hemoglobin and Hematocrit - Normal: Hemoglobin (11.5–15.0 g/dL), Hematocrit (33–45%). - Low values: Indicate blood loss or anemia, possibly from postpartum hemorrhage. - High values: Can suggest hemoconcentration (dehydration). White Blood Cell Count (WBC) - Normal: 6,000–16,000 cells/μL - Elevated: Can be normal in the first 24 hours, but levels >20,000 may indicate infection (e.g., endometritis, mastitis). Platelet Count - Normal: 150,000–400,000/μL. - Low platelets: May suggest thrombocytopenia or DIC. - High platelets: Can be a normal response to inflammation or healing. Coagulation Studies - Normal: PT (11–13.5 sec), aPTT (25–35 sec), INR (1.0). - Abnormal: Prolonged PT or aPTT could suggest bleeding disorders or DIC. Elevated D-dimer indicates clot formation. Blood Glucose - Normal: Fasting (70–100 mg/dL), Random (