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41 Cards in this Set

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What re the main physiological maternal changes in postpartum?

1. uterine involution
2. lochia flow
3. cervical involution
4. decreased vaginal distention
5. CV, GI, GU, and breast changes
What are the greatest risks during postpartum period?
hemorrhage, infection, and shock
What does oxytocin do during postpartum?
1. coordinated and strengthens the uterus
2. can prevent excessive bleeding and hemorrhage
What hormones decrease after delivery of placenta?
estrogen, progresterone, and placental enzyme insulinase
What does the decrease in hormones after placental delivery cause?
1. breast engorgement, decreased vaginal lubrication, increased sweating and urination from decreased estrogen
2. decreased progesterone causes increased muscle tone
3. decreased insulinase lowers blood glucose levels
Nursing interventions for Rh-negative mothers?
1. immune globulin within 72 hrs if infant is Rh-positive
2. Kleihauer-Betke test to determine fetal blood in circulation. above 15 ml indicates increased immune globulin
Postpartum assessments immediately after delivery?
1. vitals
2. uterine firmness, location in relation to umbilicus and midline of abdomen
3. vaginal bleeding
What is the focused postpartum physical assessment entail?
B - breasts
U - Uterus
B - Bowel and GI
B - Bladder
L - lochia (color, odor, consistency, amount) [COCA]
E - Episiotomy
Normal fundus assessment immediately postpartum?
firm, midline with umbilicus and at the same level
Fundus position 12hr after birth?
1 cm above umbilicus
When should the fundus no longer be palpable?
by day 10
Nursing interventions involving uterine involution?
1. administer oxytocics after placenta delivery
What are some oxytocics?
1. pitocin
2. methergine
3. Hemabate
4. Cytotec (is a prostaglandin)
What are the three stages of lochia?
1. rubra = bright red, fleshy odor, some clotting, lasts 1-3 days
2. Serosa = pinkish brown, serosanguineous, 4-10 days
3. Alba = yellowish, white, creamy, 11 days to 6 weeks
Terms for lochia amount on pad?
1. Scant (less than 2.5 cm)
2. Light (less than 10 cm)
3. Moderate (more than 10 cm)
4. Heavy (one pad saturated in 2 hr)
5. Excessive blood loss (one pad in 15 min, pooling of blood)
Evidence for abnormal lochia?
1. excessive spurting of bright red blood
2. numerous large clots and excessive blood loss
3. foul odor (infection)
4. Persistent lochia rubria beyond day 3 (retained placental fragments)
5. Continued flow of lochia serosa or alba beyond normal length of time (endometritis)
Comfort measures for vagina and perineum?
1. apply ice packs first 24-48 hrs
2. encourage sitz baths bid
3. analgesia and anesthetics
When is colostrum secreted?
pregnancy and 2-3 days postpartum
Nursing intervetions for client's breast and breastfeeding?
1. encourage early breastfeeding
2. assist client in comfortable positions for breastfeeding
3. teach the client th eimportant of proper latch techniques
4. educate that breastfeeding causes oxytocin release, which stimulates uterine contractions
Cardiovascular changes in postapartum?
1. decrease in blood volume
2. increased Hct and Hgb up to 72 hrs
3. leukocytosis for 10-14 days
4. coagulation elevated 2-3 weeks
Nursing interventions for cardiovascular?
1. inspect for signs of DVT
2. encourage ambulation
3. antiembolism socks to lower extremities if necessary
Nursing interventions for GI and Bowel?
1. Soften stool and promote bowel function
2. Intake and output
3. assess for hemorrhoids
Nursing interventions for GU and Bladder?
1. voiding 2-3hr
2. Excessive urination normal in first 2-3 days
3. Assess for distended bladder
4. Increase fluids
5. catheterize for bladder distention
What are some signs of distended bladder?
1. fundal height above umbilicus or baseline level
2. fundus displaced from midline to side
3. bladder bulges above symphis pubis
4. excessive lochia
5. tenderness
6. frequent voiding less than 150 ml indicates overflow
What is the immune system interventions for nursing?
1. SC injection of rubella vaccine postpartum if titer is less than 1:8
2. Hep B vaccine for newborns born to affected mothers within 12 hrs of birth
3. Rh-negative mothers with Rh positive infants must get immune globulin within 72 hrs
4. Varicella vaccine if not already immunized
5. tDaP status assessed for women
What are some signs of DVT?
1. leg pain, tenderness
2. unilateral swelling, warmth, redness
3. calf tenderness
4. MRI, Computed Tomograpy, Doppler ultrasound
What is ITP (idiopathic thrombocytopenic pupura)?
1. autoimmune
2. platelets attacked by antibodies
3. sever hemorrhage risk
What is DIC (disseminated intravascular coagulation)?
clotting and anticlotting mechanisms occur simultaneously
What are some signs of ITP or DIC?
1. unusual bleeding from gums or nose (epistaxis)
2. oozing of blood from incisions
3. petechia and ecchymoses
4. tachycardia, hypotension, diaphoresis
5. CBC, clotting factors
When is bleeding a postpartum hemorrhage?
1. >500ml after vaginal birth
2. >1,000 ml after cesarean birth
What are some signs of postpartum hemorrhage?
1. increase or change in lochial pattern
2. Uterine atony
3. Large blood clots
4. pad saturation 15 min or less
5. Tachycardia and hypotension
6. Hgb, Hct, PT time
Nursing interventions during postpartum hemorrhage?
1. monitor vitals
2. assess fundus, lochia, lacerations
3. assess bladder for distention
4. instet catheter to assess kidney function and urinary output
5. Start IV fluids with isotonic solutions
6. Oxygen 2-3 L
7. trendelenberg position
What meds are used for postpartum hemorrhage?
1. Oxytocin
2. Methergine (contraindicated for hypertension)
3. Cytotec
4. Hemabate
what is uterine atony?
Uterine muscle does not contract adequately after birth
What are some signs of uterine atony?
1. increased vaginal bleeding
2. uterus large and boggy
3. prolonged lochial discharge
4. tachycardia and hypotension
What is a subinvolution of the uterus?
1. Remained enlarged w/ continued lochial discharge
what is inversion of the uterus?
1. turning inside out of the uterus
2. partial or complete
3. an emergency
What are some signs of inversion of the uterus?
1. pain in lower abdomen
2. vaginal bleeding
3. complete sees a large, red, round mass protruding through introitus
4. partial palpates a smooth mass through dilated cervix
5. hypotension
6. dizziness
Nursing interventions for inversion of the uterus?
1. stop oxytocin
2. medications (brethine)
3. educate that c-sections needed for future pregnancies
what are some signs of retained placenta?
1. uterine atony, subinvolution, or inversion
2. excessive bleeding
3. return of lochia rubra after progression to serosa
4. elevated temperature
Nursing interventions for retained placenta?
1. monitor uterus position
2. monitor lochia
3. monitor vital signs
4. oxygen 2-3 L
5. Oxytocin