Chapter 17: Postpartum Adaptions and Nursing Care

When reading the postpartum chart the nurse notices that the patient's fundus is recorded as "u+1." The nurse understands that this means the fundus is

1 cm above umbilicus Descent of the fundus is documented in relation to the umbilicus and is measured in centimeters. Numbers with a plus sign mean that the fundus is above the umbilicus; numbers with a minus sign mean that the fundus is below the umbilicus.

weight loss after birth

10-13 lbs lost during birth from fetus, placenta, and amniotic fluid and blood loss 5-8 lbs lost from diuresis 2-3 lbs lost from involution and lochia by end of first wk

Nursing measures to promote bonding and attachment include which of the following? (Select all that apply.)

Assist the parents in unwrapping the baby to inspect Position the infant in a face to face position with the mother Nursing measures to promote bonding and attachment include: Assist the parents in unwrapping the baby to inspect the toes, fingers, and body. Inspection fosters identification and allows the parents to become acquainted with the "real" baby, which must replace the fantasy baby that many parents imagined during the pregnancy. Position the infant in an en face position and discuss the infant's ability to see the parent's face. Face-to-face and eye-to-eye contact is a first step in establishing mutual interaction between the infant and parent.

focused assessment after vaginal birth : perineum

R: redness E: edema E: ecchymosis D: discharge **A: approximation (edges are close) assessment criteria for episiotomy or perineal laceration

When assessing the perineum, episiotomy site, or surgical site, the nurse should assess for specific signs. Select all the signs that are appropriate when assessing a surgical site. (Select all that apply.)

REEDA

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be

Soft, nontender; colostrum is present. Breasts are essentially unchanged for the first 2 or 3 days after birth. Colostrum is present and may leak from the nipples. On day 3 or 4 lactation begins and engorgement can occur, resulting in the findings of b and c. Response d indicates problems with the breastfeeding techniques used.

A birthing center is trying to balance its budget and needs to cut down on certain services they have been providing. One concern of the staff is the follow-up care for new mothers. Which of the following provides follow-up care at the least cost?

Telephone counseling services Telephone calls are much less expensive than home or clinic visits. They can be used for follow-up calls to discharged patients or for parents to call for help with problems or questions. The major disadvantage is that the nurse cannot perform an in-person assessment of the mother, baby, or home environment.

The new mother is complaining of pain at the episiotomy site; however, because she is breastfeeding, she does not want any medication. What other alternatives can the nurse offer this mother to help relieve the pain?

Topical anesthetics Topical anesthetics can be applied directly to the site to numb the area. This will not cause systemic effects like pain medications. Sitz baths may also be soothing.

After a cesarean birth, the woman needs to be assessed routinely. Select all the assessments necessary for this woman. (Select all that apply.)

Vital signs Return of motion and sensation (if regional block was given) Abdominal dressing Uterine firmness and position Urine output IV infusion In addition to the usual postpartum evaluation, following cesarean birth, the mother must be assessed as any other postoperative patient: vital signs including pain, uterine position, dressing, abdomen for distention, lochia, intake (IV and oral) and output (voiding or catheter).

Preventing thrombophlebitis

ambulate early fx trips to the bathroom will help accomplish this

The development of a strong emotional tie of a parent to a newborn is called

bonding

While doing patient teaching, the woman tells the nurse, "I don't have to worry about contraception because I am breastfeeding." The nurse should base her answer on the fact that

breastfeeding is not a reliable contraceptive method. Menses in a breastfeeding mother may resume between 12 weeks and 18 months. Normally the first few cycles of menses are without ovulation; however, ovulation may occur before the first menses. Therefore other contraceptive measures are important considerations for this mother.

A mother who is 3 days postpartum calls the clinic and complains of "night sweats." She is afraid that she is going into early menopause. The nurse should base her answer on the fact that

diaphoresis is normal during the postpartum period, and comfort measures can be suggested to the mother. Diaphoresis and diuresis rid the body of excess fluids that accumulated during the pregnancy. Diaphoresis is not clinically significant, but can be unsettling for the mother who is not prepared for it. Explanations of the cause and provision of comfort measures, such as showers and dry clothing, are generally sufficient.

gastrointestinal system

digestion begins to be active new mom is very hungry from energy expended during birth and thirsty from decreased oral intake during labor and fluid loss from exertion, mouth breathing, early diaphoresis constipation is a common problem: bowel tone is diminished from progesterone relaxation of abd muscle increased constipation and distention of gas decreased food and fluid intake during labor perineal trauma, episiotomy, hemorrhoids women taking iron tx: stool softeners (COLACE) preferred over laxatives first stool in 2-3 days normal patterns of bowel elimination in 8-14 days

cervical changes after birth

dilated, edematous, bruised small tears or lacerations rapid healing takes place and by end of 1st wk the external ox is 1 cm in diameter os appears slit-like rather than round now

providing fluid and food

drink 2500 mL each day IV admin is needed meals and snacks available

Ice causes vasoconstriction and is most effective if applied soon after the birth to the perineal area to prevent

edema

One nursing measure that can help prevent postpartum hemorrhage and urinary tract infections is

encouraging voiding every 2 to 3 hours. Urinary retention and overdistention of the bladder may cause urinary tract infection and postpartum hemorrhage. Encouraging the mother to empty her bladder frequently will help prevent retention and overdistention. Forcing fluids and perineal care may assist with preventing urinary tract infections. Stool softeners assist with return of normal bowel elimination.

When the father develops a bond with the new infant and has an intense interest in how the infant looks and responds, this is called

engrossment

endocrine system

estrogen, progesterone, and human placental lactogen decline rapidly high prolactin triggers body to make milk if not breastfeeding than prolactin falls and menstruation starts

afterpains

etiology: intermittent uterine contractions more acute for multiparas from repeated stretching of muscle fibers leads to loss of muscle tone primipara tends to remain contracted but can experience severe afterpains if her uterus has been overdistended or blood clots are present severe during breastfeeding oxytocin released to stimulate milk ejection causing strong contractions of uterine muscles = pain tx: analgesics , can facilitate milk ejection reflex and is not risk during breastfeeding self limiting and decreased in fx and intensity by 3rd day ibuprofen 600-800 mg around the clock Tylenol and oxycodone

The placental site heals by a process of

exfoliation

focused assessment after vaginal birth : breast

for the first day or two after delivery the breasts should be soft and nontender after than breast changes depend largely on whether the mother is breastfeeding choose formula feeding because engorgement may occur despite preventive measures size, symmetry, and shape skin should be inspected for dimpling or thickening that can indicate breast tumor areola and nipple examined , flat and retracted nipple name breastfeeding difficult signs of nipple trauma: redness, blisters, fissures palpated for firmness and tenderness which indicates increased vascular and lymphatic circulation that may precede milk production feels "lumpy" as lobes begin to produce milk

RhoGAM

given if mother is Rh- and newborn is Rh+ and if the mother is already sensitized given 72 hrs after birth to prevent development of maternal antibodies that affect future pregnancies

vaginal changes after birth

greatly stretched vaginal walls appear edematous and multiple small lacerations may be present, very few vaginal rugae are present rugae begins to reappear by 3-4 wks 6-10 wks needed for vaginal epithelium to restore vaginal walls do not regain their thickness until estrogen production by ovaries is re-established estrogen function is not well established during lactation, breastfeeding mother experience vaginal dryness and dyspareunia (discomfort during sex)

cardiovascular system

hypervolemia increased blood volume at term, allows women to tolerate substantial blood loss during birth without ill effect up to 500 mL lost vaginally and 1000 mL lost c-section cardiac output: increase in maternal cardiac output occurs after childbirth 1. increased flow of blood back to the heart when blood from the uteroplacental unit return to the central circulation 2. decreased pressure from the pregnant uterus on the vessels which increased blood return to the heart 3. mobilization of excess extracellular fluid in the vascular compartment CO returns to non-preg levels by 6-12 wks plasma volume: diuresis: decline in adrenal aldosterone and decrease in oxytocin, up to 3000 mL/day may occur in days 2-5 diaphoresis: profuse perspiration, comfort measures like showers and dry clothing, often thirsty

providing comfort measures

ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and numb the area wrap around washcloth or paper before it is applied to the perineum , removed for 10 min before a fresh is applied again sitz bath 2-4x/day , provide continuous circulation of water, cleansing and comforting , cool water reduces pain from edema and most effective within first 24 hrs , warm water increased circulation, promotes healing, and most effective after 24 hrs analgesics: no more than 4 g of Tylenol on a day

What are the two most common complications postpartum?

infection: grand multi-parity (>5) over-distension of uterus from large baby, twins, hydramnios precipitous labor (less than 3 hrs) prolonged labor retained placenta placenta previa or accreta or placental abruption drugs (tocolytics, mag, general anesthesia, prolonged oxytocin use) operative procedures (c-section, vacuum, forceps) hemorrhage: operative procedures (c-section, vacuum, forceps) multiple cervical exams prolonged labor prolonged rupture of membranes manual extraction of placenta or retained fragments diabetes cath bacterial colonization of lower genital tract

engrossment

is an intense fascination and face to face observation b/t the parent and newborn fathers intense interest in how the infant looks and responds strong attraction fathers look forward to co-parenting with their mate they may lack confidence in providing infant care are sensitive to being left out of instructions and demonstrations of infant care

The maternal adaptation phase in which the mother relinquishes her previous role as being childless and her old lifestyle is called the _______________ phase.

letting-go

Assessments of uterine fundus and nursing actions

normal findings: fundus is firmly contracted fundus remains contracted when massage is discontinued fundus is located at or below the level of umbilicus and midline abnormal findings: 1. soft "boggy", uncontracted or difficult to locate tx: supporting lower uterine segment and massage until firm 2. fundus become soft and uncontracted when massage is stopped tx: continue to support lower uterine segment, massage fundus until firm, apply pressure to express clots, notify dr and begin oxytocin or other drug as prescribed to maintain firm fundus 3. fundus is above umbilicus and/or displaced from midline tx: assess bladder elimination, assist mom to bathroom or cath to empty bladder , recheck position and consistency of fundus after bladder is empty

Urinary system

normal function by 4 wks after delivery dilation of renal pelvis and ureters ends w/in 2-8 wks both protein and acetone may be present in urine for first few days from catabolic processes involved in uterine involution and dehydration bladder has increased capacity and decreased muscle tone edematous and traumatized diminished sensitivity to fluid pressure and little to no sensation to void bladder fills rapidly women void 500-1000 mL at at time risk for over distention of the bladder urinary retention can cause UTI risk for bleeding since uterine ligaments are displaced upward and laterally by full bladder resulting in decreased contraction of uterine muscles (uterine atony)

A new father of 1 day expresses concern to the nurse that his wife, who is normally very independent, is asking him to make all the decisions. The nurse can best explain this as a(n)

normal occurrence because the mother is in the taking-in phase. During the taking-in phase, the mother is focused primarily on her own need for fluid, food, and sleep. She may be passive and dependent. This is normal and lasts about 2 days.

focused assessment after vaginal birth : lochia

note amount, color, odor on peripads assess vaginal discharge while palpating fundus to determine amount and number of clots expressed a constant trickle, dribble, or oozing or lochai indicates excessive bleeding and required immediate attention excessive lochia in presence of a contracted uterus suggests lacerations of the birth canal .. the dr should be notified so lacerations can be located and repaired odor is fleshy, earthy, or musty a foul odor suggest endometrial infection with signs of maternal fever, tachycardia, uterine tenderness, and pain lochia should not be entirely absent , could indicate infection

changes in the perineum after birth

pelvic floor stretches and thins greatly from the fetal head during 2nd stage of labor edematous and bruised discomfort from episiotomy, hemorrhoids, trauma makes bowel elimination difficult tx: applying ice, taking sitz baths, performing perineal care, using topical anesthetics (DERMOPLAST) and cooling astringent pads, analgesics

A woman was admitted to the ED with her newborn baby. The baby was born 4 days ago at home. The woman had no prenatal care. The nurse is assessing the lab work and sees that the mother has an O-negative blood type, the baby is O-positive, and the Coombs test shows that the mother is not sensitized to the positive blood. The nurse's next action should be

record the findings of the lab work and not plan on any further action at this time. The mother is a candidate for Rho(D) immune globulin; however, it should be given within 72 hours after childbirth to prevent the development of maternal antibodies. Because she gave birth 4 days ago, that time period as passed and she is not sensitized to the positive blood.

When should mother be catheterized?

she is unable to void amount is less than 150 mL and bladder can be palpated fundus is elevated or displaced from the midline

puerperal phases

taking in phase: mom is focused on her own needs for fluid, food, and sleep . she takes in every detail of neonate but seems content to allow others to make decisions . integrates her birth experience into reality . lasts approx 2 days but prolonged with c-section taking hold phase: mother become independent , concern about managing her own body functions and assumes responsibility for her own care when she is more comfortable and in control of her body, she shifts her attention to behaviors of the infant . welcomes information about teaching and behaviors of newborn . can verbalize anxiety about competence as a mother . take advantage of this time to review taught material and provide addition info letting go phase: relinquishment for mom and father , couple must give up their previous role as child less couple and acknowledge the loss of their more carefree lifestyle give up idealized expectations relinquish infant of their fantasies and accept the real infant

verbal behaviors

talk to infant in high pitched voice may provide clues that a mothers early psychological relationship with her infant nurse observes the interactions of mothers and their infants if needed teach and model interactions that foster early attachment b/t them

During the second postpartum day, a woman asks the nurse, "Why are my afterpains so much worse this time than after the birth of my other child?" The best answer by the nurse would be:

"Afterpains are more severe for women who have already given birth." Afterpains are more acute for multiparas because repeated stretching of muscle fibers leads to low muscle tone, which results in repeated contraction and relaxation of the uterus. Breastfeeding increases the severity of afterpains. The afterpains are self-limiting and will decrease rapidly after 48 hours.

The home care nurse is visiting a new mother who delivered 1 week ago. The mother complains about not being able to sleep and that she is tired and cries easily. The best response by the nurse would be:

"It is normal for this to happen and should go away in 2 weeks. It must be very difficult for you to feel this way with a new baby." Postpartum blues begins in the first week and usually last no longer than 2 weeks. The mother needs to be supported during this time and given accurate information about the process. Responses a and b belittle the mother and may make her feel inadequate. Response d places blame on someone else and does not deal with the problem.

To promote bonding during the first hour after birth, the nurse can do which of the following? (Select all that apply.)

Delay procedures if appropriate. Allow the father to hold the newborn. Allow as much contact with the newborn as possible. Early, unlimited and prolonged contact between parents and infants is of primary importance to facilitate the bonding and attachment process. Procedures should be delayed to allow parents uninterrupted time with the newborn.

Constipation is a common problem during the postpartum period. Select all the reasons for constipation during this period. (Select all that apply.)

Diminished bowel tone Episiotomy that causes the fear of pain with elimination Iron supplementation Some pain medications Constipation may occur from decreased food and fluid intake during labor, reduced activity, iron intake, decreased muscle and bowel tone, and fear of pain during defecation.

The new parents express concern that their 4-year-old son is jealous of the new baby. They are planning on going home tomorrow and are not sure how the preschooler will react when they bring the baby home. Which one of the following suggestions by the nurse will be most helpful?

Have the mother spend time with the child while the father cares for the baby. The child needs to have the mother's love reaffirmed. By giving the child some private time with the mother, he will get the extra attention and reassurance he needs at this point.

signs of distended bladder

Location of fundus above baseline level (determine with empty bladder) Fundus displaced from midline Excessive lochia Bladder discomfort Bulge of bladder above symphysis Frequent voiding of less than 150 ml (indicate urinary retention with overflow)

pain relief after c-section

PCA (watch for resp depression, itching, N/V, urinary retention) Duramorph single dose opioid injected into epidural subarachnoid space right after sx provides 18-24 hr of analgesia itching and nausea is side effect narcan combats the itching if mom has RR of 12-14 or pulse of of <95% and on epidural narcotics than nurse should: notify anesthesia provider elevate HOB to facilitate lung expansion, instruct mom to breath deeply administer o2 and monitor pulse ox follow protocol to administer narcotic antagonist narcan observe for recurrence of resp depression because duration of naloxone is only 30 min recognize narcan may reduce level of pain relief auscultate bowel sounds and monitor I/Os

immunizations

Rubella: screening done on each women to determine immune status, given after birth if not immune, rubella can cause serious fetal anomalies during preg vaccine is attenuated live DONT BECOME PREGNANT 28 DAYS AFTER ADMINISTRATION 0.5 mL sub-q can appear in breastmilk and cause rash to infant, not contraindication , tested for immune status 6-8 wks after to verify immunity keep in fridge, discard after 8 hrs if not used, protect from sunlight pertussis: full protection is not achieved until series is complete adults should have booster is handling children younger than 12 mo varicella: women not immune to varicella should receive first dose of vaccine after delivery and before discharge from the birth facility , be advised not to become pregnant for 1 mo after receiving the vaccine

Resumption of Ovulation and Menstruation

anovulatory for first few cycles after birth normally, but some ovulation can still occur contraceptive use to prevent recurrent of pregnancy non-nursing moms will resume menstruation in 6-10 wks breastfeeding moms: delay return of ovulation and menstruation, starts back b/t 10wks-6mo

When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically

attempt to meet the needs of the infant and is eager to learn about infant care. One week after birth the woman should exhibit behaviors characteristic of the taking-hold phase. This stage lasts for as long as 4 to 5 weeks after birth. Responses a and b are characteristic of the taking-in stage, which lasts for the first few days after birth. Response d reflects the letting-go stage, which indicates that psychosocial recovery is complete.

postpartum blues

baby blues, affects 70-80% of new mothers, lasts about 2 weeks, must be distinguished from postpartum depression or postpartum psychoses peaks around 5 days irritable, fatigue, tearfulness, mood swings, anxiety condition does not seriously affect the mothers ability to care for the infant let family know this is normal and self limiting

focused assessment after vaginal birth : bladder elimination

determine whether bladder is distended bladder distention often produces an obvious or palpable bulge that feels like a soft, movable mass above the symphysis pubis include an upward and lateral displacement of the uterine fundus and increased lochia fx voids of less than 150 mL suggest urinary retention signs of empty bladder include a firm fundus in the midline and a nonpalpable bladder 2-3 voids should be measured after birth or the removal of a cath to determine whether normal bladder function has returned 300-400 mL voiding means bladder is fully empty regardless of amount voiding, if the fundus is displaced when assessed, it should be assessed again after the woman void to confirm that the bladder is empty

neurologic system

discomfort and fatigue after childbirth are common after pains, an episiotomy, laceration, incision, muscle aches, and breast engorgement may increase a women's discomfort and ability to sleep analgesia and anesthesia can cause temp neuro changes, prevent injury from falling ** complaints of headache require careful assessment frontal and bilateral headaches are common in first wk from result in change in fluid and electrolyte balance severe headaches are not common and may be from postdural puncture headaches (most severe when pt is upright, relieved when lying down)

A nurse is asked to do a home visit on a woman who delivered 2 weeks ago. When assessing the woman, the nurse was not able to locate the fundus. The next action would be

document this normal finding. The uterus descends at the rate of about 1 cm/day. By 10 to 14 days, it is no longer palpable above the symphysis pubis. This is a normal finding.

lactation

estrogen and progesterone prepare the breasts for lactation prolactin rises during preg but lactation is inhibited since estrogen and progesterone are so high after expulsion of placenta, estrogen and progesterone decline rapidly and prolactin initiates milk production w/in 2-3 days continues with suckling of baby oxytocin needed for milk ejection or let down reflex and milk is expressed from alveoli into lactiferous ducts during suckling

integumentary system

estrogen, progesterone, and melanocyte-stimulating hormones decline then skin goes back to normal melasma (mask or preg), linea nigra, spider nevi, and palmar erythema fade away striae gravidarum gradually fade into silvery lines but do not disappear hair loss begins 4-20 wks but is back by 4-6 mo

descent of the uterine fundus

immediately after delivery uterus is grapefruit/softball size and 1 kg, weighs 1000 grams palpated midway b/t symphysis pubis and umbilicus and in the midline of the abd after 12 hrs: fundus rises to level of umbilicus descends approx 1 cm (fingerbreadth) per day, by day 14 is can no longer be palpated abdominally if this process does not occur = subinovulation: cause postpartum hemorrhage U-1 indicates fundus is palpable about 1 cm below the umbilicus weight of uterus decreases to approx 500 g (1 lb) at 1 wk and weighs 2-3 oz at 4 wks

involution of the uterus

involution is change of reproductive organs, particularly uterus, undergo after childbirth to return to non-pregnant size and condition 1. contraction of muscle fibers 2. catabolism (process of converting cells into simpler compounds) 3. regeneration of uterine epithelium begins after delivery of the placenta contraction controls bleeding from the area left when the placenta is separated outer portion is endometrial layer is expelled with placenta in 2-3 days decidua (endometrium during preg) separates in two layers (superficial layer shed with lochia and basal layer grows new endometrium) regeneration takes 2-3 wks healing at site of placenta occurs more slowly and requires 6 wks

The day after giving birth, the woman complains that she did not lose all the weight she had gained during the pregnancy. The nurse can best respond to the mother with the knowledge that

it will take about 6 to 12 months for all the weight gained with the pregnancy to disappear. Women are very concerned about regaining their normal figure. Nurses must emphasize that weight loss should be gradual and that about 6 to 12 months is usually required to lose most weight gained during pregnancy.

focused assessment after vaginal birth : lower extremities

legs examined for variscosities and signs of thrombophlebitis localized area of redness, heat, edema, and tenderness pedal pulses may be obstructed by thrombus and should be palpated with each assessment

The nurse is assessing the patient's vaginal discharge. It is red and has about a 2-inch stain on the peripad. The nurse will record this finding as a

light amount of lochia rubra Lochia rubra is red in color and occurs the first 3 or 4 days after birth. A light amount of discharge is classified as a 1- to 4-inch stain on the peripad.

lochia

lochia rubra: days 1-3, bloody, small clots, fleshy/earthy odor, dark red or red-brown .. the amount of blood decreases when WBCs increase abnormal: large clots, saturated peri pad, foul odor lochia serosa: day 3-10, decreased amount, serosangunious, pink or brown tinged, composed of serous exudate, RBCs, WBCs, cervical mucus .. by day 10 the RBC decrease and white/cream/yellow discharge follows abnormal: excessive amount, foul smell, continued recurrent reddish color lochia alba: day 10-14, contains WBCs, decidual cells, epithelial cells, fat, cervical mucus, bacteria, can end by day 14 or persist until the end of the 3rd-6th wk abnormal: persistent lochia serosa, return to lochia rubra, foul odor, discharge continuing scant: 1 inch light: 1-4 inch moderate: 6 in heavy: saturated in 1 hr excessive: saturated in 15 min flow is greater immediately after delivery, less after c-section due to endometrial lining is removed during sx heavier for when mom first gets out of bed after birth or after sleeping because gravity allows blood pooling

hematologic system

marked leukocytosis may occur WBC count rise to 30K in immediate postpartum period not related to infection , but increase in 30% over 6 hrs could mean infection WBC falls to normal 6 days after birth coagulation: plasma fibrinogen increases, greater ability to from clots and prevent excessive bleeding, continued risk for thrombus formation, take 4-6 wks before hemostasis returns to normal levels EARLY POSTPARTUM AMBULATION , ted hose

maternal touch

maternal behavior changes rapidly as mother progresses through discovery phase with her infant initially mother may not touch infant, but hold baby en face position with face in same vertical plane as her own so they can have eye contact prolonged mutual gazing she may explore infants face, fingers, and toes with her fingertips only at first stroke babys chest and legs with her palm then use entire hand claiming: identify specific features and related them to family members

Immediately after birth, the nurse can anticipate the fundus to be located

midway between they symphysis and umbilicus. Immediately after birth the uterus is about the size of a large grapefruit and the fundus can be palpated midway between the symphysis pubis and umbilicus. Within 12 hours the fundus rises to the level of the umbilicus. By the second day, the fundus starts to descend by approximately 1 cm/day.

maternal role attainment and role conflict

mother achieves confidence in her ability to care for infant and becomes comfortable with her identity as a mother anticipatory stage: begins in pregnancy, classes formal stage: birth of infant and continues for 4-6 wks, behaviors guided by others, learn infant cues informal stage: mom learns baby cues and signals personal stage: mother accepts the role of parent and feels comfortable in this role

musculoskeletal system

muscles and joints: muscle fatigue and aches warmth and gentle massage helps during first few days, levels of hormone relaxin subside, and ligaments and cartilage of pelvis begins to return to their normal position can cause hip and joint pain good body mechanics and correct posture* abdominal wall: tone is diminished diastasis recti: longitudinal muscles of abd may separate gentle exercise to strengthen abd wall returns to normal position in 6 wks

On the first postpartum day a patient's white blood cell count is 25,000/mm3. The nurse's next action should be to

note the results in the chart. Marked leukocytosis occurs during the postpartum period. The WBC count increases to as high as 30,000/mm3. The WBC count should fall to normal values by day 7. Neutrophils, which increase in response to inflammation, pain, and stress to protect against invading organisms, account for the major increase in WBCs. Because this is a normal reading, noting the results in the chart is the appropriate action.

When assessing a woman who gave birth 2 hours ago, the nurse notices a constant trickle of lochia. The uterus is well contracted. The next nursing action should be to

notify the physician Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. The uterus is well contracted, so further massage is not necessary.

The new mother comments that the newborn "has his father's eyes." The nurse recognizes this as

part of the bonding process termed claiming. Claiming or binding-in begins when the mother begins to identify specific features of the newborn. She then begins to relate features to family members.

focused assessment after vaginal birth : edema and DTR

pedal and pre-tibial edema present for first few days until excess interstitial fluid is remobilized and excreted diuresis is highest b/t 2-5th day after birth DTR should be 1+ to 2+ , report brisker-than-average and hyperactive reflexes 3+, 4+ which suggest preeclampsia

A newborn is rooming-in with his teenage mother, who is watching TV. The nurse notes that the baby is awake and quiet. The best nursing action is to

pick the baby up and point out his alert behaviors to the mother. Modeling behavior by the nurse is an excellent way to teach infant care. The inexperienced teenage mother can observe the proper skills and then the nurse can encourage her to try those skills.

During the early post-cesarean section phase, it is important for the woman to turn, cough, and deep breathe. The rationale for this is to prevent

pooling of secretions in the airway. The post-cesarean section woman is usually on bed rest for the first 8 to 12 hours. She is at risk for pooling of secretions in the airway. By assisting her to turn, cough, and expand her lungs by breathing deeply at least every 2 hours, the pooling of secretions will be decreased.

nursing care of postpartum family

postpartum assessment: 48 hrs after vaginal 96 after c-section initial assessment: vitals skin color location and firmness of fundus amount of color of lochia, perineum (edema, episiotomy, lacerations, hematoma) presence, degree, and location of pain IV infusions (type of fluid, rate of admin, type and amount added of meds, patency of line, redness, pain, edema at site) infusion pump urine output (time and amount of last void or cath, presence of cath, color, character of urine) make sure cath is drained status of abd incision and dressing level of feeling and ability to move if regional anesthesia was administered chart review: G , P (hemorrhage risk) time and type of delivery (vacuum, forceps, 1st or 2nd c-section) presence and degree of episiotomy or lacterations anesthesia or meds administered medical and surgical hx (DM, HTN, heart disease) medications given during labor or delivery food and drug allergies chosen method of infant feeding condition of the baby lab data: prenatal Hgb and Hct, blood type, Rh factor, Hep B surface antigen, rubella immune status, syphilis screen, group B strep status

attachment

process by which and enduring bond b/t parent is developed through pleasurable, satisfying interaction begins in preg and extends months after birth reciprocal attachment behaviors: both directions from infant to parents, infants part in the process of early attachment that progresses to lifelong mutual devotion newborn infants have ability to do following: make eye contact and engage in prolonged, intense, mutual gazing move their eyes and attempt to track the parents face grasp and hold parents finger move synchromnously in response to rhytmns and patterns of parents voice (called entrainment) root, latch onto breast, and suckle be comforted by parents voice or touch

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing women's needs during this stage, should

provide time for the mother to reflect on the events of the childbirth. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also in the care of the newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions and using written materials to reinforce the content presented are a more effective approach.

focused assessment after vaginal birth : vital signs

q 15 min after 1st hr q 30 min after 2nd hr q 4 hrs for 1st 24 hrs q 8-12 hrs thereafter done more fx if findings are abnormal or mother has additional risk factors know baseline BP: orthostatic hypotension: rapid decrease in intraabdominal pressure results in dilation of blood vessels supplying the viscera, engorgement of abd blood vessels contribute to rapid fall in BP of 15-20 mmHg systolic when women moves from the recumbent position to the sitting position hypotension could indicate hypovolemia HR: bradycardia is 40-50 bpm, blood returning to central circulation increases the stroke volume with lowers HR to provide adequate maternal circulation tachycardia indicates pain, excitement, anxiety, fatigue, dehydration, hypovolemia, anemia, or infection RR: 12-20 , could lower from smoking, mag, ashtma, URI Temp: 100.4 in first 24 hrs is normal, response to dehydration or normal postpartum leukocytosis , if persists longer than 24 hrs than worry for infection Pain: discomfort, inability to sleep, change in vitals, restless, irritable, facial grimace

bonding

rapid initial attraction felt by parents for their infants unidirectional from parent to child enhanced when parents and infants are permitted to touch and interact during the first 30-60 minutes after birth nurse can delay procedures to facilitate this

The first time a woman ambulates after the birth of the newborn, she has a nursing diagnosis of Risk for injury because of the

risk for developing orthostatic hypotension. After birth a rapid decrease in intraabdominal pressure results in dilation of the blood vessels supplying the viscera. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in blood pressure when the woman moves from a recumbent to a sitting position. The mother feels dizzy or lightheaded and may faint when she stands. Bradycardia is a normal change during the postpartum period. The cardiac output increases during the postpartum period, but does not produce orthostatic hypotension.

focused assessment after vaginal birth : fundus

should be firmly contracted and at or near level of umbilicus if uterus is above and shifted away from midline (usually right) than bladder may be distended have mom empty bladder, than re-check placement of the fundus if soft or boggy than MASSAGE THE UTERUS UNTIL FIRM to reduce risk for hemorrhage uterus contracts only when it is free of clots so massage to ensure uterus is free support lower uterine segment to prevent inversion of the uterus nurse will apply firm pressure down toward vagina to expel clots drugs are sometimes needed to maintain contraction of uterus and prevent hemorrhage most common is oxytocin (Pitocin)

episiotomy

surgical incision of the perineal area begins healing in 2-3 wks and complete by 6 4-6 mo discomfort: from walking, sitting, stooping, squatting, bending, urinating, and defecating

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should

take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being to care for their baby effectively.