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A nurse is caring for a patient who has excessive blood loss post-delivery from uterine atony. The perinatal nurse notifies the health-care provider while another nurse performs uterine massage. Which medication does the nurse anticipate to be given as the priority? a. Carboprost (Hemabate) b. Ergonovine (Ergotrate) c. Methylergonovine (Methergine) d. Oxytocin (Pitocin)
Pitocin
You are assigned a woman who is 5 hours post-birth. She gave birth to an 8-pound girl and experienced a 4th degree tear of the perineum. During your postpartum assessment, she informed you that she has rectal pressure and severe pain where she tore. Her level of pain is 10 on a pain scale of 0-10. You note her perineum is intact with minimal bruising. Her blood pressure is 100/60 and pulse is 98. Based on this assessment data, select the best initial nursing action. a. Medicate her for pain b. Notify her physician of your assessment data c. Place an ice pack on her perineum d. Assist her in ambulating to the bathroom
Place an ice pack on her perineum
How often are VS taken for vaginal birth?
Q15 mins for first hour, Q30 for second hour, once during third hour, then Q8H
How often are VS taken for C-Section?
Q30 x4, Q1H x4, then Q4-8H
Renal system, fluid & electrolytes
Renal plasma flow, GFR, Cr & BUN, pregnancy associated proteinuria, rapid diuresis and natriuresis
The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? a. She should repeatedly contract and relax her rectal and thigh muscles. b. She should practice by stopping the urine flow midstream every time she voids. c. She should get on her hands and knees whenever performing the exercises. d. She should be taught that toned pubococcygeal muscles decrease blood loss.
She should practice by stopping the urine flow midstream every time she voids.
The perinatal nurse is teaching the patient about breastfeeding and explains that which of the following is the most appropriate time to breastfeed? a. Four to 5 hours after the last feeding b. Only when her infant exhibits hunger-related crying c. When her infant is in a quiet alert state d. When her infant is in an active alert state
When her infant is in a quiet alert state
The nurse is caring for a postoperative cesarean client, the woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? a. Failed lactogenesis b. Dysfunctional parenting c. Wound dehiscence d. Projectile vomiting
Wound dehiscence
Signs and symptoms of postpartum depression include which of the following? [mark all correct answers] a. Sleep and appetite disturbances b. Uncrontrolled crying c. Delusions d. Feelings of guilt and/or worthlessness
a, b, d
Which of the following factors place a woman at risk for thrombosis? [mark all correct answers] a. Obesity b. Physiological changes of pregnancy c. Metritis d. Cesarean birth
a, b, d
The nurse is preparing a woman in the early postpartum period for a fundal check. Select all appropriate nursing actions: [mark all correct answers] a. Provide for privacy b. Position the woman in high Fowler's position c. Have the patient empty her bladder d. Position the patient in the supine position
a, c, d
Treatment of mastitis
abx, application of heat or cold, hydration, analgesics, frequent emptying of breasts, asses for signs of thrush in the infant
Treatment for endometritis
abx, rest, increased fluids, antipyretics, good nutrition, good perineal care, and promote uterine drainage
E-emotions
affect, patient-family interaction, effects of exhaustion
Late hemorrhage
after 24 hours-12 weeks
S/sx of pulmonary embolus
anxious, diaphoretic, low o2, impending doom
Your patient, who gave birth to a 7-pound baby boy 24 hours ago, is complaining of uterine cramping (afterpains). This is her second baby and she is breastfeeding. Your assessment reveals a firm fundus at midline at 1 cm below the umbiliucus. Select all of your initial nursing actions. [mark all correct answers] a. Instruct the patient to bottle-feed for 36 hours or until the cramping has stopped. b. Place a warm blanket on her abdomen c. Explain that these are normal for second-time mothers to experience. d. Offer the patient acetaminophen with codeine so she can continue to breastfeed.
b, c
puerperal infection
bacterial infection that occurs within 28 days after miscarriage, induced abortion or childbirth. Infection of the endometrium, can also include UTI or mastatis
Hemorrhage
blood loss great than 500 mL after vaginal birth, 1,000 mL after C-section
Treatment of pulmonary embolus
call physician, oxygen, IV, fluids, heparin, and pain medicatoin
Onset of wound infection
can happen as early as 48 hours or as late as a week after deliveries
ducts
collects milk from alveoli, stores the milk, deliver to nipple
Postpartum blues
common, 50-80% of women have some degree, should last less than 2 weeks. S/sx- tired, anxious, tearful, mood swings. Treatment- rest, relaxation, having someone to talk to to listen
Lobes
contain alveoli
Estrogen and progesterone dramatically _____ -> stimulates anterior pituitary gland to produce prolactin
decrease
Reproductive system
decrease in uterine size, return of ovulation and menstruation
Pros of shorter hospital stay
decreased risk of infections, DVTs, and decreased medical expenses
S/sx of endometritis
elevated temp, uterine tenderness, foul smelling lochia, cramping pain
S/sx of septic pelvic thromboplebitis
fever, chills, pelvic pain, when treated with abx it doesn't go away with just abx, do further studies
S/sx of wound infection
fever, pain, chills, warmth of incision, foul smelling drainge, etc
B-breasts
inspection of nipples, everted, flat, inverted? Breast tissue-soft, filling, firm? Temperature and color-warm, pink, cool, red streaked?
Heparin
labs-APTT, antidote-protamine sulface
Coumadin/warfarin
labs-PT/INR, antidote-Vitamin K
B-bladder
last time the patient emptied her bladder (spontaneously or via catheter) . Palpable or nonpalpable? Color, odor, and amount of urine
oxytocin ->
letdown of milk
Hematoma
localized collection of blood in connective or soft tissue under the skin
U-uterus
location (midline or deviated to right/left) tone (firm, firm with massage, boggy)
Alveoli
make the milk
Causes of mastitis
milk stasis, plugged milk duct, infrequent breastfeeding, and fissure in the nipple. Inflammation, edema, enlarged axillary nodes, breast engorgement with obstruction of milk flow
Postpartum hemorrhage complications
more likely to have blood product exposure, ICU admission, additional surgeries, infection, prolonged hospitalization, thromboembolism
Pros of longer hospital stay
more time to rest, education time, time to identify anomalies in the infant or other problems, good breastfeeding routines
Musculoskeletal system
muscle fatigue/soreness r/t stress and excursion during labor, diastasis recti abdominis
S/sx of mastitis
normal signs of infection, plus warmth, redness, hard areas, redness underneath the breast
What do you do if you notice PP hemorrhage?
notify physician, fundal massage, frequent VS, palpate bladder, measurement of blood loss, bimanual compression, oxygen, labs (CBC, coagulation studies, type & cross match), large bore IV access
Management of hematomas
notify physician, if <3-5 cm-ice, Sitz baths, pain medication. If >5 cm-might require an I&D to remove it. If shock-then progress to shock management
L-legs
pain, varicosities, warmth or discoloration in calves, presence of pedal pulses, sensation and movement (after C-Section)
Risk factors of hematomas
pain/pressure, vaginal heaviness, rectal pressure, bluish discoloration, bulging of tissue, tenderness to touch, if large-can have symptoms of hypovolemia
Risk factors for wound infection
poor hygiene, not frequent enough pad changes, anything that delays wound healing, anemia, diabetes, obesity, prolonged labor, prolonged rupture of membranes
5% of all women who give birth vaginally have
postpartum hemorrhage
Too dilute formula can lead to
problems with undernourishment and water intoxication
need to the continued suctioning and oxytocin to keep releasing ___ for milk production
prolactin
Postpartum pscyhosis
rare, dramatic onset. Have lack of interest, mood swings, tearfulness, hallucinations, delusions, confusion, suicidal or homicidal thoughts. Treatment: hospitalization, mood stabilizer, antipsychotic meds, anti-anxiety meds, ECT, long term pscyhotherapy
REEDA
redness, edema, ecchymosis, drainage, approximation
S/sx of Thrombophlebitis & thrombosis
redness, warmth, swelling, pain, increased calf circumference in one leg. Some people are asymptomatic
hPL, cortisol, growth hormone & insulin also decrease ->
reduces anti-insulin effects; often BS in normal range for fist few days after delivery
Risk factors of UTI
relaxation of bladder tone, vaginal exams, trauma from birth, epidurals (can't tell they have to go to the bathroom)
Respiratory system
respiratory alkalosis, & compensated metabolic acidosis, decrease in intra-abdominal pressure
Involution
restoring uterus back to pre-pregnancy size. Should go down one finger breadth/day
Cardiovascular system
heart returns to normal position, cardiac output is elevated for first complete hours after delivery, RhoGAM & reubella administration
Too concentrated formula can lead to
hyperatremia which can lead to dehydration
decrease estrogen/progesterone ->
increase in prolactin
WBC will increase or decrease after birth?
increase, should return to normal around day 6
Septic pelvic thrombophlebitis
infected blood clot causes inflammation in a pelvic pain
Thrombophlebitis & thrombosis
inflammation of the venous circulation and blood clot formation
Tissue associated with hemorrhage
retained placental tissue, can't heal, will have open vessels, where there had been an injury to the uterine wall. Placenta previa, previous abortion, previous D&C, previous C-Section, etc.
Risk factors of thrombophlebitis & thrombosis during pregnancy
smokes, obese, other chronic health problems, immobile
Problems that result in ineffective breastfeeding
sore nipples (improper latch on), breast engorgement
Prolactin ->
stimulate alveoli to make milk
Suckling of infant ->
stimulate oxytocin release
Trauma associated with hemorrhage
to soft tissues, cervical trauma, vaginal trauma, some sort of laceration internally, forceps delivery, lacerations. Will see blood flowing out of vagina, uterus will be firm
tone associated with hemorrhage
tone of uterus, uterine atony (lack of tone), anything that overextends the uterus, prolong labor, infection, etc
4 T's associated with hemorrhage
tone, trauma, tissue, thrombin
Postpartum depression
two or more symptoms of postpartum blues that exist most or all of the day; occurring up to within 1 year after birth
E-episiotomy/laceration
types as well as other tissue trauma (lacerations, etc.) assess using REEDA
Integumentary
usually all disappear, except for stretch marks typically
Early hemorrhage
within first 24 hours, most common right after birth
A nurse is providing discharge teaching to a postpartum patient who is bottle feeding. The patient asks the nurse when she should expect to have her period return. The nurse's best response is: a. "You can expect to have your period in 3-4 weeks." b. "Many women who choose not to breastfeed will have a period in 6-8 weeks after childbirth." c. "Your period will return at about 6 months post-delivery" d. "Bottle feeding suppresses ovulation, so as long as you bottle feed, you will not have a period.
"Many women who choose not to breastfeed will have a period in 6-8 weeks after childbirth."
A diabetic patient is 1 day postpartum after an uncomplicated vaginal birth. She wants to know why her blood sugar levels are so much lower than usual. What explanation by the nurse is best? a. "Because you are dehydrated, your blood sugar decreases for a few days." b. "I will call the dietician to see if you are getting enough calories." c. "The levels of hormones that cause an anti-insulin effect are decreased." d. "The exertion from childbirth is like a massive workout for your body."
"The levels of hormones that cause an anti-insulin effect are decreased."
The perinatal nurse accurately defines postpartum hemorrhage to a group of nursing students by including a decrease in hematocrit levels from prebirth to postbirth by which percentage? a. 5% b. 8% c. 10% d. 15%
10%
Onset of endometritis
2-4 days after childbirthq
Onset of mastitis
2-4 weeks postpartum
A woman with postpartum depression is in the perinatal clinic for follow-up. The health-care provider tells the nurse that the patient will be prescribed a tricyclic antidepressant. The nurse will instruct the patient about which medication? a. Fluoxetine (Prozac) b. Pamelor (Nortriptyline) c. Sertraline (Zoloft) d. Venlafaxine (Effexor)
Pamelor (Nortriptyline)
To decrease the risk of orthostatic hypotension during the first few hours after the birth, the nurse should: a. Assist the patient to the bathroom by using a wheelchair b. Break open an ammonia ampule and have teh patient take a deep breath before getting up c. Have the patient sit on the side of the bed for a few minutes before standing d. Check the patient blood pressure before assisting her to the bathroom
Have the patient sit on the side of the bed for a few minutes before standing
Hct will decrease or increase after birth?
Increase, usually become of concentration in the blood
Thrombin associated with hemorrhage
has to do with maternal coagulation, low platelets, placenta abruption, can lead to D&C, etc
Your patient is a 25-year-old gravida 1 woman who is 2 hours postpartum. You note on assessment that her fundus is firm and midline. She is experiencing a steady stream of blood. The bed linen under her is soaked in blood. Based on these findings and observations, you suspect that she is exhibiting early signs/symptoms of a postpartum hemorrhage related to: a. Uterine atony b. Laceration of the cervical or vaginal area c. Retained placental tissue d. Fibroids
Laceration of the cervical or vaginal area
D-discomfort
Location, severity, pharmacological and non pharmacological measures.
A postpartum woman has a deep vein thrombosis. The patient states, "I feel anxious and have some pain in my chest." The patient's respiratory rate is 28 breaths per minute. After calling for help, which action by the perinatal nurse takes priority? a. Administer oxygen. b. Document the findings. c. Take a full set of vital signs. d. Prepare to give pain medication.
Administer oxygen.
A postpartum woman who had a cesarean birth complains of warmth and pain in one of her calves. Which assessment should the nurse perform as the priority? a. Bilateral calf circumference b. Homans' sign on both legs c. Lung sounds and oxygen saturation d. Pedal and popliteal pulses
Bilateral calf circumference
Risk factors of endometritis
C-Section, prolonged labor, multiple vaginal exams, internal fetal monitoring, anything that causes delayed wound healing
Risk factors for septic pelvic thrombophlebitis
C-section, prolonged or difficult labor, forceps or vacuum, multiple exams, other infection
L-lochia
Color, amount presence of clots, any free flow?
Your patient gave birth to a 6-pound baby girl 6 hours ago. It was a spontaneous delivery. You note on your assessment of her perineum that there is some edema and slight bruising. She stated that her pain was at a 1 on the pain scale. Your nursing action would be: a. Continue applying ice to the perineum b. Assist her with a sitz bath c. Encourage her to empty her bladder d. Administer ibuprofen 800 mg.
Continue applying ice to perineum
Women who experience mastitis should be instructed to: a. Stop breastfeeding until 48 hours after the start of antibiotic therapy b. Continue to breastfeed or massage and express mik from the affected breast c. Wash nipples with antibiotic soap before each feeding session. d. Apply cream to nipples after each feeding until the mastitis has resolved.
Continue to breastfeed or massage and express milk from the affected breast
B-bowels
Date/time of last BM; presence of flatus or hunger (unless the color was manipulated, do not need to auscultate for bowel sounds)
Hgb will do what after birth? Increase or decrease
Decrease
A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4°F (38°C). What action by the nurse is best? a. Encourage the woman to drink plenty of fluids. b. Document the findings and notify the provider. c. Have the woman cough and deep breathe. d. Prepare to administer acetaminophen (Tylenol).
Encourage the woman to drink plenty of fluids.
GI system
GI motility continues to be decreased, constipation commmon
Oxytocic drugs
Oxytocin, cytotec, methergine, ergotrate, hemabate, prostin E
