OB Exam 3
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make?
"Apply cold compresses between feedings"
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make?
"Completely empty each breast at each feeding or use a pump"
Client Education and Discharge Teaching
"Discharge teaching is an important aspect of postpartum care. It is important for a client to be able to perform self-care and recognize effects that suggest possible complications prior to discharge." "Discharge planning should be initiated at admission with time spent during the hospitalization on providing client education regarding postpartum self-care." "A nurse should use a variety of teaching strategies to promote learning. Return demonstrations are important to ensure that adequate learning has taken place."
A nurse is completing a postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching?
"I need a second vaccination at my postpartum visit"
A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? (select all that apply)
"I will drink large amounts of fluids to flush the bacteria from my urinary tract" "I will take Tylenol for any discomfort"
A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching?
"Wear a supportive bra continuously for the first 72 hours"
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client?
"Your son is showing an adverse sibling response"
Infections:
Complications that can occur... Up to 28 days following childbirth or an abortion (spontaneous or induced) Fever of 100.4 or higher for 2 consecutive days Infection can be in bladder, uterus, wound, or breast Can lead to septicemia Early identification and prompt treatment are necessary to promote positive outcomes!
Retained placenta laboratory tests
Hgb and Hct
Postpartum hemorrhage lab tests
Hgb and Hct Coagulation profile (PT) Blood type and crossmatch
Postpartum hemorrhage expected findings
Increase or change in lochial pattern (return to previous stage, large clots) Physical Assessment Findings Uterine atony (hypotonic or boggy) Blood clots larger than a quarter Perineal pad saturation in 15 min or less Constant oozing, trickling, or frank flow of bright red blood from vagina Tachycardia and hypotension Skin pale, cool, and clammy with loss of turgor and pale mucous membranes Oliguria
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia cause by hemorrhage?
Increase pulse and decreasing blood pressure
Uterine atony client education
Instruct the client to limit physical activity to conserve strength and to increase iron and protein intake to promote the rebuilding of RBC volume.
Postpartum
Interval between birth and return of reproductive organs to their normal non-pregnant state Traditionally considered 6 weeks but recovery varies Greatest risk: hemorrhage, shock, infection
Retained placenta diagnostic procedures
Manual separation and removal of the placenta is done by the provider. D&C if oxytocics are ineffective in expelling the placental fragments
Sibling Adaptation: Assessment
Nursing assessment of sibling adaptation to the infant includes the following: Assess for positive responses from the sibling: interest and concern for the infant, increased independence Assess for adverse responses from the sibling: signs of sibling rivalry and jealousy, regression in toileting and sleep habits, aggression toward the infant, increased attention-seeking behaviors and whining
Retained placenta risk factors
Partial separation of a normal placenta Entrapment of a partially or completely separated placenta by constricting ring of the uterus Excessive traction on the umbilical cord prior to complete separation of the placenta Placental tissue that is abnormally adherent to the uterine wall Preterm births between 20 and 24 weeks of gestation
A nurse is providing care to four clients n the postpartum unit. Which of the following clients is at greatest risk for developing postpartum infection?
A client who does not wash their hands between perineal care and breastfeeding
A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection?
A client who had premature rupture of membranes and prolonged labor
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, mid-line, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?
A normal postural discharge of lochia
Fundus patient-centered care
Administer oxytotics IM or IV after the placenta delivers to avoid hemorrhage Oxytocin, methylergonovine (Methergine), and carboprost (Hemabate) Misoprostol (Cytotec), a prostaglandin, may also be used Monitor adverse effects of medications Oxytocin and misoprostol can cause hypotension Methylergonovine, ergonovine, and carboprost can cause hypertension Encourage early breastfeeding Encourage emptying of bladder
Postpartum hormonal changes
After placental delivery, hormones (estrogen, progesterone, and placental enzyme insulinase) decrease Decreased estrogen = Breast engorgement Diaphoresis (especially at night) Diuresis (of IV fluid received during labor & extracellular fluid accumulated during pregnancy) Vaginal lubrication (may persist until ovarian function returns and menstruation resumes) Decreased progesterone = Increased muscle tone throughout the body Decreased insulinase = Reversal of the diabetogenic effects of pregnancy
Mastitis:
An infection of the breast involving the interlobular connective tissue and is usually unilateral. Mastitis can progress to an abscess if untreated. It occurs most commonly in mothers breastfeeding for the first time and well after the establishment of milk flow, which is usually 6 weeks after delivery Staphylococcus aureau is usually the infecting organism.
Uterine Atony medications
As noted for postpartum hemorrhage.
Inversion of the Uterus patient-centered care
Assess for an inverted uterus Visualize the introitus Perform a pelvic exam Maintain IV fluids Administer oxygen Stop oxytocin if it is being administered at the time uterine inversion occurred Avoid excessive traction on the umbilical cord Anticipate surgery if nonsurgical interventions and management are unsuccessful
Cervix, vagina, and perineum: Assessment
Assess for cervical, vaginal, and perineal healing Observe the perineum for erythema, edema, and hematoma Assess episiotomy and lacerations for: Approximation Drainage- quantity and quality A bright red trickle of blood from the episiotomy site in the early postpartum period is a normal finding
Fundus assessment
Assess fundal height, uterine placement, and uterine consistency every 8 hours after initial 2 hours Explain procedure to the client Apply clean gloves and lower perineal pad to observe lochia flow as the fundus is palpated Cup one hand just above the pubic bone to support the lower segment of the uterus (avoid prolapse) and massage the fundus with the other hand Document fundal height, location and uterine consistency Measure fundal height using hands Determine midline or displaced Firm or boggy (if boggy, massage until firm)
Lacerations and hematomas patient-centered care
Assess pain Visually or manually inspect the vulva, perineum, and rectum for lacerations and/or hematomas Assess an episiotomy for extension into a third-or-forth degree laceration Evaluate lochia Continue to assess vital signs and hemodynamic status Attempt to identify the source of bleeding Assist the provider with repair procedures Use ice packs to treat small hematomas Administer pain medication Encourage sitz baths and frequent perineal hygiene Can cause vasodilation- monitor client's pulse
Urinary system and bladder function assessment
Assess the urinary system and bladder function: Assess the client's ability to void every 2 to 3 hours (perineal/urethral edema may cause pain and difficulty in voiding for 24-48 hours) Assess bladder elimination pattern (should be every 2-3 hours) Excessive diuresis is normal within the first 2-3 days postpartum Assess for evidence of a distended bladder Fundal height above the umbilicus or baseline level Fundus displaced from the midline Bladder bulges above the symphysis pubis Excessive lochia Tenderness over bladder area Frequent voiding of less than 150 mL (retention with overflow) Stress incontinence
Mastitis: physical assessment findings
Axillary adenopathy in the affected side (enlarged tender axillary lymph nodes) with an area of inflammation that can be red, swollen, warm, and tender
Uterine Atony Diagnostic procedures
Bimanual compression or manual exploration of the uterine cavity for retained placental fragments by the provider Surgical management, such as a hysterectomy
A nurse on the postpartum unit is assessing a client who is being admitted with suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? (select all that apply)
Calf tenderness to palpation Elevated temperature Area of warmth
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply)
Demonstrates apathy when the newborn cries Views the newborn's behavior as uncooperative during diaper changing
DVT diagnostic procedures
Doppler ultrasound scanning Computed tomography Magnetic resonance imaging
Sibling Adaptation: complications
Emphasize verbal and nonverbal communication skills between the client, caregivers, and the infant Provide continued assessment of the client's parenting abilities, as well as any other caregivers for the infant Encourage continued support of grandparents and other family members Provide home visits and group sessions for discussion regarding infant care and parenting problems Give the client and caregivers information about social networks that provide a support system where they can seek assistance. Involve outreach programs concerned with self-care, parent-child interactions, child injuries, and failure to thrive Notify programs that provide prompt and effective community interventions to prevent more serious problems from occurring
Breast patient-centered care
Encourage early demand breastfeeding- helps establish milk supply later and production of oxytocin Assist the client into a comfortable position, and have her try various positions during breastfeeding Football, cradle, across the lap, side-lying Explain to the client how various holds can prevent nipple soreness Proper latch techniques Inform client that cramping during breastfeeding is normal
Management of Thrombophlebitis
Encourage rest Facilitate bed rest and elevation of the client's extremity above the level of her heart (avoid using a knee gatch or pillow under knees) Administer intermittent or continuous warm moist compresses Do NOT massage the affected limb to prevent thrombus from dislodging and becoming an embolus. Measure the client's leg circumferences. Provide thigh-high antiembolism stockings for the client at high risk for venous insufficiency Administer analgesics (nonsteroidal anti-inflammatory agents) Administer anticoagulants for DVT
Urinary system and bladder function patient-centered care
Encourage the client to empty her bladder frequently (every 2 to 3 hours) to prevent possible displacement of the uterus and atony Measure the client's first few voidings after delivery to assess bladder for emptying Encourage the client to increase her oral fluid intake to replace fluids lost at delivery and to prevent or correct dehydration Catheterize if necessary for bladder distension if the client is unable to void to ensure complete emptying of the bladder and allow uterine involution
Uterine Atony patient-centered care
Ensure that the urinary bladder is empty Monitor the following: Fundal height, consistency, and location Lochia for quantity, color, and consistency Perform fundal massage if indicated If the uterus becomes firm, continue assessing hemodynamic status If uterine atony persists, anticipate surgical intervention, such as a hysterectomy Express clots that can have accumulated in the uterus, but only after the uterus is firmly contracted. It is critical not to express clots prior to the uterus becoming firmly contracted because pushing on an uncontracted uterus can invert the uterus and result in extensive hemorrhage Monitor vital signs Maintain or initiate IV fluids Provide oxygen at 2 to 3 L/min per nasal cannula
A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (select all that apply)
Epidural anesthesia Urinary bladder catheterization Frequent pelvic examinations History of UTIs
Phases of Maternal Role Attainment nursing considerations
Facilitate the bonding process by placing the infant skin-to-skin or in the enface position with the client immediately after birth Promote rooming-in as a quiet and private environment that enhances the family bonding process Promote early initiation of breastfeeding, and encourage the client to recognize infant readiness cues. Offer assistance if needed. Teaching the client about infant care facilitates bonding as the client's confidence improves. Encourage parents to bond with the infant through cuddling, bathing, feeding, diapering, and inspection. Provide frequent praise, support, and reassurance to the client as she moves toward independence in caring for her infant and adjusting to her maternal role. Encourage parents to express feelings, fears, and anxieties about caring for the infant.
Postpartum hemorrhage patient-centered care
Firmly massage the uterine fundus Monitor vital signs Assess for source of bleeding Assess fundus for height, firmness, and position. If uterus is boggy, massage fundus to increase muscle contraction. Assess lochia for color, quantity, and clots Assess for clinical findings of bleeding from lacerations, episiotomy site, or hematomas Assess bladder for distention. Insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output. Maintain or initiate IV fluids to replace fluid volume loss with IV isotonic solutions, volume expanders, and blood products as needed Provide oxygen at 2 to 3 L/min per nasal cannula, and monitor oxygen saturation Elevate the client's legs to a 20 to 30 degree angle to increase venous return
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking , the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take?
Give the client time to express feelings
DVT Medications
Heparin Classification: Anticoagulant Therapeutic Intent: Given IV to prevent formation of other clots and to prevent enlargement of the existing clot Nursing Considerations Initially, IV heparin is administered by continuous infusion for 3 to 5 days with doses adjusted according to coagulation studies. Protamine sulfate, the heparin antidote, should be readily available to counteract the development of heparin-induced antiplatelet antibodies. Monitor aPTT (1.5 to 2.5 times the control level of 30 to 40 seconds) Client Education: Instruct the client to report bleeding from gums or nose, increased vaginal bleeding, blood in the urine, and frequent bruising. Warfarin Classification: Anticoagulant Therapeutic Intent: Used fro treatment of clots. It is administered orally and is continued by the client for approximately 3 months. Nursing Considerations Phytonadione, the warfarin antidote, should be readily available for prolonged clotting times Monitor PT (1.5 to 2.5 times the control level of 11 to 12.5 seconds) and INR of 2 to 3 Client Education Instruct the client to watch for bleeding from the gums or nose, increased vaginal bleeding, blood in the urine, and frequent bruising. Instruct the client to use birth control to avoid pregnancy due to teratogenic effects of warfarin. Oral contraceptives are contraindicated because of the increased risk for thrombosis.
Postpartum physical assessment
Immediately following delivery Monitor vital signs Uterine firmness, location, and midline position Amount of vaginal bleeding ACOG recommends BP and pulse be checked Q15min for 2 hrs after birth and temp every 4 hrs for the first 8 hrs, then every 8 hrs B:breast U:uterus (fundal height, uterine placement, and consistency) B:bowel (and GI function) B:bladder function L:lochia (color, odor, consistency, and amount) E:episiotomy (edema, ecchymosis, approximation) Vital signs to include pain assessment Teaching needs
Uterine Atony expected findings
Increased vaginal bleeding Uterus that is later than normal and boggy with possible lateral displacement on palpation Prolonged lochial discharge Irregular or excessive bleeding Tachycardia and hypotension Skin that is pale, cool, and clammy with loss of turgor and pale mucous membranes
Assessing a Client's Knowledge of Postpartum Care
Inquire about the client's current knowledge regarding self-care Assess the client's home support system and who will be there to assist. Include support system persons in the educational process. Determine the client's readiness for learning and her ability to verbalize or demonstrate the information she has been given. Always be supportive, but encourage the client to perform newborn care activities herself Low risk vaginal delivery: discharged 24 to 36 hours after delivery C-section delivery: discharged 48 to 96 hours after delivery The health of the mother and her newborn should be stable, the mother should be able and confident to provide care for her infant, and there should be adequate support systems in place and access to follow-up care
postpartum hemorrhage client education
Instruct the client to limit physical activity to conserve strength, to increase iron and protein intake to promote rebuilding of RBC volume, and take iron with vitamin C to enhance absorption.
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest?
Kegel exercises
postpartum diagnostic procedures
Labs CBC with monitoring of Hgb, Hct, WBC, and platelets Diagnostic: Rh-negative Mothers Rho(D) immune globulin (Rho-gam) Given within 72 hours of birth Kleihauer-Betke test: amount of fetal blood in maternal circulation- if more than 15 mL, increased Rho-gam dose given
Lacerations and hematomas expected findings
Lacerations Sensation of oozing or trickling of blood Excessive rubra lochia (with or without clots) Hematoma Pain Pressure sensation in rectum (urge to defecate) or vagina Difficulty voiding Physical Assessment Findings Laceration: vaginal bleeding even though the uterus is firm and contracted, continuous slow trickle of bright red blood from vagina, laceration, episiotomy Hematoma: bulging, bluish mass or area of red-purple discoloration on vulva, perineum, or rectum
Lacerations and hematomas
Lacerations that occur during labor and birth consist of tearing of soft tissues in the birth canal and adjacent structures including the cervical, vaginal, vulvar, perineal, and/or rectal areas. An episiotomy can extend and become a third- or fourth-degree laceration A hematoma is a collection of 250 to 500 mL of clotted blood within tissues that can appear as a bulging bluish mass. Hematomas can occur in the pelvic region or higher in the vagina or broad ligament. Pain, rather than noticeable bleeding, is distinguishable clinical finding of hematomas. The client is at risk for hemorrhage or infection due to a laceration or hematoma.
Postpartum alteration in ovarian function and menstruation
Lactating and nonlactating women differ in timing of their first ovulation and the resumption of menstruation In lactating women, serum prolactin levels remain elevated and suppress ovulation Return of ovulation is influenced by: Breastfeeding frequency Length of each feeding Use of supplementation Infant's suck First ovulation = approximately 6 months Nonlactating: Prolactin decreases to prepregnant level by 3rd PP week Ovulation: 27-75 days after birth Menses: 4 to 6 weeks after birth
DVT expected findings
Leg pain and tenderness Unilateral area of swelling, warmth, and redness Hardened vein over the thrombosis Calf tenderness
Lochia assessment
Lochia amount is assessed by the quantity of saturation on the perineal pad as being: Scant: less than 2.5 cm Light: 2.5 to 10 cm Moderate: More than 10 cm Heavy: One pad saturated within 2 hours Excessive blood loss: one pad saturated in 15 min or less, or pooling of blood under the buttocks Assess the lochia for color, amount, consistency Typically trickles, but may flow more heavily during a contraction- should stop trickling Assess for pooled lochia
Inversion of the Uterus diagnostic procedures
Manual replacement of the uterus into the uterine cavity and repositioning of the uterus by the provider
A nurse is planning care for a client who is postpartum and had thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care?
Measure leg circumferences
Mastitis risk factors
Milk stasis from a blocked duct Nipple trauma and cracked or fissured nipples Poor breastfeeding technique with improper latching of the infant onto the breast, which can lead to sore and cracked nipples Decrease in breastfeeding frequency due to supplementation with bottle feeding Poor hygiene and inadequate hand washing when handling perineal pads and touching the breast
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document?
Moderate lochia rubra
Retained placenta patient-centered care
Monitor the uterus for fundal height, consistency, and position Monitor lochia for color, amount, consistency, and odor Monitor vital signs Maintain or initiate IV fluids Provide oxygen at 2 to 3 L/min per nasal cannula Anticipate surgical interventions, such as a D&C or hysterectomy, if postpartum bleeding is present and continues
Breast assessment
Nurse should assess the breasts as well as her ability to help the newborn latch Colostrum (early milk) transitions to mature milk by 72 to 96 hours after birth ("milk coming in") Engorgement: result of lymphatic circulation, milk production, and temporary vein congestion Redness and tenderness of the breast Cracked nipples and signs of mastitis (infection of a milk-duct with flu like symptoms) Ensure newborn is latched correctly to avoid nipple soreness Ineffective newborn feeding patterns related to maternal dehydration, maternal discomfort, newborn positioning, or difficulty with the newborn latching onto the breast
Phases of Maternal Role Attainment assessment
Nursing assessments include noting the client's condition after birth, observing the maternal adaptation process, assessing maternal emotional readiness to care for the infant, and assessing how comfortable the client appears in providing infant care. Assess for behaviors that facilitate and indicate mother-infant bonding Considers the infant a family member Holds the infant face-to-face (en face position), maintaining eye contact Assigns meaning to the infant's behavior and views this positively Identifies the infant's unique characteristics and relates them to those other family members Names the infant, indicating bonding is occurring Touches the infant and maintains close physical proximity and contact Provides physical care for the infant, such as feeding and diapering Responds to the infant's cries Smiles at, talks to, and sings to the infant Assess for behaviors that impair and indicate a lack of mother-infant bonding Apathy when the infant cries Disgust when the infant voids, stools, or spits up Expresses disappointment in the infant Turns away from the infant Does not seek close physical proximity to the infant Does not talk about the infant's unique features Handles the infant roughly Ignores the infant entirely Does not include the infant in the family context Perceives infant behavior as uncooperative Assess for manifestations of mood swings, conflict about maternal role, or personal insecurity Feelings of being "down" Feelings of inadequacy Feelings of anxiety related to ineffective breastfeeding Emotional lability with frequent crying Flat affect and being withdrawn Feeling unable to care for the infant
Lochia patient-centered care
Nursing interventions for abnormal lochia include Notifying the provider Performing prescribed interventions based on the cause of the abnormality Manifestations of abnormal lochia Excessive spurting of bright-red blood from the vagina (cervical or vaginal tear) Numerous large clots and excessive blood loss (1 pad in 15 min) (hemorrhage) Foul odor (infection) Persistent lochia rubra after 3 days (retained placental fragments) Continued serosa or alba with fever and pain (endometritis)
DVT Incidence and Etiology
Occurs in 1 of every 1,000 pregnancies VTE and DVT can occur at anytime during pregnancy, but PE usually occurs after delivery and is a major cause of maternal death Main causes are venous stasis and hypercoagulation C-section doubles the risk for VTE
Lacerations and hematomas risk factors
Operative vaginal birth (forceps-assisted, vacuum assisted birth) Precipitous birth Cephalopelvic disproportion Size (macrosomic infant) an abnormal presentation of position of the fetus Prolonged pressure of the fetal head on the vaginal mucosa Previous scarring of the birth canal from infection, injury, or operation Clients who are nulliparous are at greater risk for injury due to firmer and less resistant tissue Women who have light skin, especially those with reddish hair, have less distensible tissue than women who are dark skin.
Postpartum hemorrhage medications
Oxytocin Classification: Uterine stimulant Therapeutic Intent: Promotes uterine contractions Nursing considerations: Assess uterine tone and vaginal bleeding Monitor for adverse reactions of water intoxication, such as lightheadedness, nausea, vomiting, headache, and malaise. These reactions can progress to cerebral edema with seizures, coma, and death. **Methylergonovine** Classification: Uterine stimulant Therapeutic Intent: Controls postpartum hemorrhage Nursing considerations: Assess uterine tone and vaginal bleeding. Do not administer to clients who have hypertension. Monitor or adverse reactions, including hypertension, nausea, vomiting, and headache. Misoprostol Classification: Uterine stimulant Therapeutic Intent: Controls postpartum hemorrhage Nursing Considerations: Assess uterine tone and vaginal bleeding Carboprost tromethamine Classification: Uterine stimulant Therapeutic Intent: Controls postpartum hemorrhage Nursing Considerations: Assess uterine tone and vaginal bleeding Monitor for adverse reactions, including fever, chills, headache, nausea, vomiting, and diarrhea
Retained placenta medications:
Oxytocin (to contract the uterus and expel placental fragments) and terbutaline (to relax the uterus prior to D&C) Client Education Instruct the client to limit physical activity and increase iron intake.
Inversion of the Uterus expected findings
Pain in the lower abdomen Vaginal bleeding: hemorrhage Complete inversion as evidenced by a large, red, rounded mass that protrudes 20 to 30 cm outside the introitus Partial inversion as evidenced by the palpation of a smooth mass through the dilated cervix Dizziness Low blood pressure, increased pulse (shock) Pallor
Mastitis: expected findings
Painful or tender localized hard mass and reddened area, usually on one breast Chills Fatigue
Paternal Adaptation: Transition
Paternal adaptation takes place as the father develops a parent-infant bond. The father has skin-to-skin contact, holds the infant, and maintains eye-to-eye contact with the infant The father observes the infant for features similar to his own to validate his claim of the infant The father talks, sings, and reads to the infant Transition Paternal transition to fatherhood consists of a predictable three-stage process during the first few weeks of transition Expectations and intentions: The father desires to be deeply and emotionally connected with the infant Confronting reality: The father discovers that his expectations might not be met. Commonly expressed emotions include feeling sad, frustrated, and jealous. He embraces the need to be actively involved in parenting. Reaping rewards: Rewards include infant smiles and a sense of completeness and meaning
Cervix, vagina, and perineum: patient-centered care
Perineal tenderness, laceration, and episiotomy Promote measures to help soften the client's stools Educate the client about proper cleansing to prevent infection. The client should: Wash her hands thoroughly before and after voiding Use a squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse the perineal area Clean her perineal area from front to back (urethra to anus) Blot dry, not wipe Sparingly use a topical application of antiseptic cream or spray Change perineal pad after voiding and defecating Promote comfort measures Ice packs the first 24 to 48 hours Sitz baths Administer analgesia, such as non-opioids (acetaminophen), NSAIDs (ibuprofen), and opioids (codeine, hydrocodone) for pain and discomfort. Opioid analgesia may be administered via a patient-controlled analgesia (PCA) pump after cesarean birth. Continuous epidural infusions may also be used for pain control after cesarean birth. Apply topical anesthetics (benzocaine spray) to client's perineal area as needed or witch hazel compresses to the rectal area for hemorrhoids.
Cervix, vagina, and perineum
Physical changes: The cervix is soft directly after birth and can be edematous, bruised, and have small lacerations. Within 2 to 3 days postpartum, it shortens, regains it's form, and becomes firm, with the os gradually closing (changing the shape of the opening). Lacerations can delay the production of estrogen-influenced cervical mucus and are a predisposing factor to infection. The vagina, which has distended, gradually returns to its prepregnant size with the reappearance of rugae and a thickening of the vaginal mucosa. However, muscle tone is never restored completely. The soft tissues of the perineum can be erythematous and edematous, especially in areas of episiotomy or lacerations. Hematomas or hemorrhoids can be present. Pelvic floor muscles can be overstretched and weak.
Breasts:
Physical changes: secretion of colostrum (during pregnancy and 2-3 days after birth), milk production (3 to 5 days after delivery of the newborn)
Postpartum physical changes
Physiological and psychological adjustments include: Uterine involution, lochia flow, cervical involution, decreased vaginal distention, alteration in ovarian function and menstruation, cardiovascular, urinary tract, breast, and gastrointestinal changes
Breast care: Lactating clients
Place the newborn skin-to-skin as soon as possible following birth and initiate breastfeeding within the first 1 to 2 hours after birth unless contraindicated Wear a well-fitting, supportive bra continuously for the duration of lactation Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection To relieve breast engorgement: have client empty breasts each feeding, allow the infant to nurse on demand (8 to 12 times in a 24 hour period or about every 2 hours), massage the breasts during feeding to enhance emptying, allow the infant to feed until the breast softens, use pump if needed until the breasts are softened, alternate starting breast each feeding, can apply cabbage leaves to relieve engorgement For breast engorgement: apply cool compresses after feedings and apply warm compresses, or take warm show prior to breastfeeding (these actions will increase milk flow and promote the let down reflex) For flat or inverted nipples: make nipples erect before feeding (using fingertips or latch assist) to make it easier for the infant to latch properly For sore nipples: apply a small amount of breastmilk to the nipple and allow to dry before or after feedings, change the infant's position for breastfeeding; start breastfeeding with the nipple that is less sore Apply breast creams and wear breast shields if nipples are irritated or cracked Promote adequate fluid intake
A nurse in the delivery room is planning to promote parent-infant bonding for a client who is just delivered. Which of the following is the priority action by the nurse?
Position the neonate skin-to-skin on the client's chest
lochia
Post birth discharge that contains blood, mucus, and uterine tissue Three stages of lochia Rubra Bright red color, bloody consistency, fleshy odor, can contain small clots, transient flow increases during breastfeeding and upon rising. Lasts1 to 3 days post delivery Serosa Pinkish brown color, serosanguinous consistency, and lasts from day 4 to 10 post delivery Alba Yellow/white creamy color, fleshy odor, and lasts day 11 to 4-8 weeks postpartum
Postpartum therapeutic procedures
Postpartum chill Occurs within first 2 hours after birth Uncomfortable shaking chill following birth Possibly nervous system response, vasomotor changes, shift in fluids, and/or work of labor Normal occurrence unless accompanied by an elevated temp Provide warm blankets and fluids Assure client that chills are self-limiting, common occurrence, and they will only last a short while Sitz bath :)
Postpartum hemorrhage
Postpartum hemorrhage is considered to occur if the client loses more than 500 ml blood after a vaginal birth or more than 1,000 ml blood after a cesarean birth. Two complications that can occur following postpartum hemorrhage include hypovolemic shock and anemia.
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (select all that apply)
Precipitous delivery Inversion of the uterus Retained placental fragments
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition?
Preeclampsia
DVT risk factors
Pregnancy Cesarean Birth (doubles the risk) Operative vaginal birth Pulmonary embolism and varicosities Immobility Obesity Smoking Multiparity Age greater than 35 years History of thromboembolism Diabetes mellitus
DVT patient-centered care
Prevention of Thrombophlebitis Provide the client with education and encouragement pertaining to measures for prevention of DVT. Maintain sequential compression device until ambulation is established If bed rest is prolonged longer than 8 hours, perform active and passive range of motion to promote circulation in the legs if warranted. Initiate early and frequent ambulation postpartum. Avoid prolonged periods of standing, sitting, or immobility Have the client elevate her legs when sitting Tell the client to avoid crossing her legs, which will reduce the circulation and exacerbate venous stasis. Maintain fluid intake of 2 to 3 L each day from food and beverage sources to prevent dehydration, which causes circulation to be sluggish. Tell the client to discontinue smoking. Measure the lower extremities for fitted elastic thromboembolic hose to lower extremities.
Indications of Potential Complications
Provide client education on indications of potential complications to report to the provider: Chills and fever (greater than 100.4 for 2 days) Change in vaginal discharge (increased amount, clots, change to a previous lochia color, such as bright red bleeding, and a foul odor) NORMAL LOCHIA FLOW PATTERNS: Rubra: Dark red vaginal drainage for 1 to 3 days Serosa: Brownish red or pink vaginal drainage from days 3 to 10 Alba: Yellowish white vaginal discharge after day 10 to 6 weeks Episiotomy, laceration, or incisional pain (does not resolve with analgesics, foul-smelling drainage, redness, and/or edema) Pain or tenderness in the abdominal or pelvic area (that does not resolve with analgesics) Breast(s) with localized areas of pain and tenderness (with firmness, heat, and swelling, and/or nipples with cracks, redness, bruising, blisters, or fissures) Calves with localized pain, tenderness, redness, and swelling- have client elevate leg until she can be seen Urination with burning, pain, frequency, urgency Postpartum depression: feeling apathy toward infant, cannot provide care for self and/or infant, feelings that she might hurt herself or the newborn Also educate the client on postpartum blues that may last 1-2 weeks Follow-up visit: Vaginal delivery- 4 to 6 weeks, cesarean birth- 2 weeks. Date and time of visit should be written and discussed in the discharge instructions
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding.The parent appears very anxious and nervous hen asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?
Provide education about infant care when the parent is present.
Patient-Centered Care: Mastitis
Provide the client with education regarding breast hygiene to prevent and manage mastitis Instruct the client to thoroughly wash hands prior to breastfeeding Instruct the client to maintain cleanliness of breast with frequent changes of breast pads Encourage the client to allow nipples to air-dry Teach the client proper infant positioning and latching-on techniques, including both the nipple and areola. The client should release the infant's grasp on the nipple prior to removing the infant from the breast. Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth Encourage the client to use ice or warm packs on the affected breast for discomfort
Lacerations and hematomas theraputic procedures
Repair and suturing of the episiotomy or lacerations is done by the provider. Ligation of the bleeding vessel or surgical incision for evacuation of the clotted blood from the hematoma is done by the provider.
Inversion of the Uterus risk factors
Retained placenta Uterine atony Vigorous fundal pressure Abnormally adherent placental tissue Fundal implantation of the placenta Excessive traction applied to the umbilical cord Short umbilical cord Prolonged labor
Uterine Atony risk factors
Retained placental fragments Prolonged labor Oxytocin induction or augmentation of labor Overdistention of the uterine muscle (multiparity, multiple gestations, polyhydramnios, macrosomic fetus) Precipitous labor Magnesium sulfate administration as a tocolytic Anesthesia and analgesia administration Trauma during labor and birth from operative delivery (forceps or vacuum assisted birth, cesarean birth
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
Sore nipple with cracks and fissures.
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis?
Staphylococcus aureus
Sibling Adaptation: Nursing actions
Take the sibling on a tour of the obstetric unit Encourage the parents to do the following: Let the sibling be one of the first to see the infant Provide a gift from the infant to give the sibling Arrange for one parent to spend time with the sibling while the other parent is caring for the infant Allow older siblings to help in providing care for the infant Provide preschool-aged siblings with a doll to care for Encourage the parents to take time for siblings and provide a little extra care and attention during the adjustment period
Inversion of the Uterus medications
Terbutaline Classification: Tocolytic Therapeutic Intent: To relax the uterus prior to the provider's attempt at replacement of the uterus into the uterine cavity and uterus repositioning Nursing Considerations (following replacement of the uterus into the uterine cavity) Closely observe the client's response to treatment and assess for stabilization and hemodynamic status Avoid aggressive fundal massage Administer oxytocics as prescribed Administer broad-spectrum antibiotics for infection prophylaxis Client Education: Inform the client that a cesarean birth will be needed for subsequent pregnancies.
Sibling Adaptation: Introduction
The addition of an infant into the family unit affects everyone in the family, including siblings who can experience a temporary separation from parents. Siblings become aware of changes in the parents' behavior because the infant requires much more of the parents' time.
Risk factors for infections:
The immediate postpartum period following birth is a time of increased risk for all women for micro-organism entering the reproductive tract and migrating into the blood and other parts of the body, which can result in life-threatening septicemia Urinary tract infection, mastitis, pneumonia, or history of previous venous thrombus History of diabetes mellitus, immunosuppression, anemia, or malnutrition History of alcohol or drug use disorder Cervical dilation that provides the uterus with exposure to the external environment through the vagina Well-supplied exposed blood vessels Wounds from lacerations, incisions, or hematomas Alkalinity of amniotic fluid, blood, and lochia during pregnancy and the early postpartum period, decreasing the acidity of the vaginal secretions Cesarean birth Prolonged rupture of membranes Retained placental fragments and manual extraction of the placenta Chorioamnionitis Internal fetal/uterine pressure monitoring Multiple vaginal examinations after rupture of membranes Prolonged labor Postpartum hemorrhage Operative vaginal birth Epidural analgesia/anesthesia Hematomas Episiotomy or lacerations
Retained placenta
The placenta or fragments of the placenta remain in the uterus and prevent the uterus from contracting, which can lead to uterine atony or subinvolution.
Urinary system and bladder function
The urinary system can show evidence of the following: Urinary retention (loss of elasticity and tone, loss of sensation); can cause uterine atony Postural diuresis with increased urinary output begins within 12 hours of delivery
Phases of Maternal Role Attainment:
Three phases: Dependent: taking-in phase First 24 to 48 hours Focus on meeting personal needs Rely on other for assistance Excited, talkative Need to review birth experience with others Dependent-independent: taking-hold phase Begins on day 2 or 3 Lasts 10 days to several weeks Focus on baby care and improving caregiving competency Want to take charge but needs acceptance from others Wants to learn and practice Dealing with physical and emotional discomforts, can experience "baby blues" Interdependent: letting-go phase Focus on family as a unit Resumption of role (intimate partner, individual)
Deep-vein thrombosis
Thrombophlebitis refers to a thrombus (Blood Clot) that is formed/associated with inflammation. Thrombophlebitis of the lower extremities can be of superficial or deep veins, which are most often of the femoral, saphenous, or popliteal veins. The postpartum client is at greater risk for a deep-vein thrombosis (DVT) that can lead to a pulmonary embolism.
A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? (select all that apply)
Use perineal squeeze bottle to cleanse the perineum Apply a topical anesthetic cream or spray to the perineum Apply cold or ice packs to the perineum
Postpartum hemorrhage risk factors
Uterine atony Overdistended uterus Previous history of uterine atony Prolonged labor, oxytocin-induced labor High parity Ruptured uterus Complications during pregnancy (e.g. placenta previa, abruptio placentae) Precipitous delivery Administration of magnesium sulfate therapy during labor Lacerations and hematomas Inversion of uterus Subinvolution of the uterus Retained placental fragments Coagulopathies (DIC)
Uterine Atony
Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage.
Retained placenta expected findings
Uterine atony, subinvolution, or inversion Excessive bleeding or blood clots larger than a quarter Return of lochia rubra once lochia has progressed to serosa alba Malodorous lochia or vaginal discharge Elevated temperature
Endometritis:
Uterine infection is also referred to as endometritis Infection of the uterine lining or endometrium Most frequently occurring puerperal infection Usually begins on the second to fifth postpartum day as a localized infection at the placental attachment site and spreads to include the entire uterine endometrium
Fundus intro
Uterine involution Return of uterus to a nonpregnant state after birth Subinvolution: most common causes retained placenta and infection Oxytocin (hormone released from pituitary gland) coordinates and strengthens uterine contractions (before and after delivery) Breastfeeding stimulates release of oxytocin Exogenous oxytocin can be administered postpartum to improve quality of uterine contractions. Firm contracted uterus prevents excessive bleeding and hemorrhage. Contractions clamp down on the open blood vessels (like stepping on a water hose) Uncomfortable uterine cramping is referred to as afterpains (more common after first baby) Uterus at the end of 3rd stage Midline Approxamatiely 2 cm below the level of the umbilicus Within 12 hrs, fundus can rise approximately 1 cm above the umbilicus By 24 hrs fundus is at the level is was at 20 weeks (above the level of the umbilicus) After first 24 hrs fundus descends 1 to 2 cm every 24 hrs Should not be palpable after 2 weeks Non-pregnant level by 6 weeks 1 week postpartum: 500 g 2 weeks postpartum: 350 g 6 weeks postpartum: 60 to 80 g
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony?
Uterine retention
Breast care: Non-Lactating clients
Wear a well-fitting, supportive bra continuously for the first 72 hours Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating For breast engorgement, which can occur on the third or fifth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics or anti-inflammatory medication can be taken for pain and discomfort of breast engorgement
Inversion of the Uterus
is the turning inside out of the uterus and can be partial or complete. Uterine inversion is an emergency situation that can result in postpartum hemorrhage and requires immediate intervention.
