OB Exam II - Postpartum and Women's Health Unit
After-birth uterus pain...
- Lasts 2-3 days - Caused by: * oxytocin * prostaglandins * OVER DISTENDED UTERUS! d/t large baby, multiples, multiparous, breastfeeding (increased oxytocin), and exogenous exytocin medicine
What should the nurse be doing during her mom assessments in the immediate postpartum period?
Answer: - Be aware of H&H, WBCs - Assist 1st time out of bed - Encourage activity as tolerated - BE ALERT TO THROMBUS FORMATION! (especially in the legs) Look for --> * pain, tenderness * redness, warmth * calf size, edema * Homan's sign (though it is better to just check for any pain while mom is ambulating) --> used really for mom's with epidural, anesthesia
What kinds of CARDIOVASCULAR changes would you expect to see during the immediate Puerperium period following birth?
Answer: - Blood volume lessened d/t diuresis directly after delivery --> Avg blood loss for vaginal birth = 300-500 cc --> Avg blood loss for c-section birth = 500-1,000 cc - CO increased in first 24 hrs postpartum, returning to normal within 2 weeks postpartum - CLOTTING FACTORS INCREASED! which means women during this period are at increased risk for developing thromboembolism --> ESPECIALLY in the lower extremities, assess for pain and color changes!
What is the appropriate amount/timing for nursing assessments in the immediate postpartum period?
Answer: - Check the mom as follows: q15 min x 1hr q30 min x 1hr q1-2 hrs x 2 (or up to 4-8 hrs) THEN q8 hrs - Remember, ASSESSMENTS SHOULD NOT INTERFERE WITH BREASTFEEDING & FAMILY BONDING!
3rd Degree Lacerations...
Answer: - Involves 2nd degree laceration + 5) tear through the entire thickness of anal sphincter, 6) the muscle retracts into the surrounding tissue and can be difficult to see, 7) a partial 3rd degree is a sheering of muscle fibers of the sphincter and.... - Requires repair!
Interventions for (uterine) bleeding include...
Answer: - Massage --> guard uterus above symphysis! - Breastfeeding - Medications = 1. Pitocin 2. Ergot drugs (erogonovine, methergine) 3. Prostaglandin (cyctotec, hembabate)
What kinds of VITAL SIGNS would you expect to see during the immediate Puerperium period following birth?
Answer: - Temp up to 100.4 F (38 C) in 1st 24 hrs postpartum --> may occur as result of dehydration and exertion from labor - Tachycardia --> EARLY SIGN OF EXCESSIVE BLOOD LOSS - Remember, respirations may be effected by meds given before, during, and post labor - Blood pressure is WITHIN NORMAL LIMITS! --> Increased BP (+ proteinuria) = consider pre-eclampsia --> Decreased BP = excessive blood loss
Describe the nursing assessment of the uterus in the immediate postpartum period
Answer: - have mom go to the bathroom before beginning assessment (why? 1) bladder fills quickly w/PP diuresis; 2) full bladder interferes w/effectiveness of uterine contractions) - lie the mother in a nearly FLAT position - palpate fundal height & location (using finger widths) - note any displacement - evaluate uterus consistency --> * Firm * Firm with massage * Boggy
Cervix Changes Postpartum
Answer: - original form returns in a few hours - fingertip size opening by 1 week - PERMANENT CHANGES in shape (becomes more open, shape more of an oval, called parous! - Need to refit diaphragm/cervical cap @ 6 week postpartum check
Interventions for after-birth uterus pain...
Answer: - warm compresses - alternatives --> relaxation, deep breathing, imagery, distraction, interaction with NB, etc. - Medications (before nursing) --> NSAIDs, narcotics if severe - keep bladder empty - reassure: lessen each day!
Describe fundal height changes in postpartum hr 12, days 1-8, day 9, and by weeks 5-6
Answer: IMMEDIATELY AFTER BIRTH - 2cm below umbilicus 12 hrs - 1cm above umbilicus 1-8 days - decreases about 1cm/day Day 9 - NOT PALPABLE! 5-6 weeks - near non-pregnant size
What is the process of involution?
Answer: Postpartum (post placenta delivery) - theres a decrease in estrogen and progesterone leading to --> * autolysis = process of self destruction and reabsorption of the proteins which had gotten the uterine muscle cells bigger NOTE: a large number of these hypertrophied cells remain after pregnancy/delivery (hyperplasia state) --> resulting in a slightly larger sized uterus
What is involution?
Answer: Process of the uterus returning to a non-pregnant state, usually begins to happen after delivery of the placenta (3rd stage of labor) UTERUS SHRINKING!
Define Puerperium
Answer: "The fourth trimester" lasting 6-8+ weeks post birth - time after the birth of a baby, when repro. organs return to ALMOST pre-pregnant state. - also consisting of RAPID physiologic changes immediately after birth
What kinds of HEMATOLOGIC changes would you expect to see during the immediate Puerperium period following birth?
Answer: - Hemoglobin and hematocrit altered! Values of Hgb/Hct LESS THAN OR EQUAL TO 10/30 considered anemia --> remember Normal levels (women) * Hgb = 12-16 * Hct = 36-42 - WBCs are elevated --> this is considered NORMAL, neutrophils are most commonly elevated - Plasma fibrinogen and clotting factors remain at pregnancy levels (so increased!) for the first week postpartum
2nd Degree Lacerations and Episiotomy...
Answer: - Involves 1) vaginal mucosa, 2) posterior fourchette, 3) perineal skin, 4) AND perineal muscles - Always repaired!
First Degree Lacerations...
Answer: - Involves 1) vaginal mucosa, 2) posterior fourchette, and 3) perineal skin - May be left unrepaired if not bleeding
4th Degree Lacerations...
Answer: - an extension of the third degree laceration into the mucosa of the rectum --> essentially the skin of the rectal sphincter is disturbed! - Nothing per rectum postpartum orders (no suppositories, enema)
Determining Lochia Amounts
Answer: - assessed by the extent of saturation of peripad SCANT = <2.5 cm LIGHT = <10 cm MODERATE = >10 cm HEAVY = 1 pad saturated within 1hr
What processes facilitate involution?
Answer: - breastfeeding - fundal massage - medications --> * pitocin = causing rhythmic uterine contractions * methergine = causing sustained uterine contractions
What kinds of RESPIRATORY changes would you expect to see during the immediate Puerperium period following birth?
Answer: - diaphragm returns to normal (look at all of this space!!) - lungs able to fully expand - O2 consumption normalizes
What processes interfere with involution?
Answer: - full bladder - prolonged labor - difficult birth - anesthesia - retained placenta - grand multipara (multiple births) - over-distention - infection - clots!
Lochia changes and characteristics...
Answer: 1. Color changes = 1st 2-3 days --> rubra, dark red, some small clots 3rd to 10 days --> serosa, pink, brown 10th to 21st days --> alba, yellow, clear 2. Odor = fleshy (shouldn't be foul) 3. Amount (generally increases with activity) = * Scant, moderate, heavy --> ABNORMAL to saturate pad in less than or equal to 1/hr * May not small amount of oozing with fundal massage in first few days * MONITOR FOR LARGE CLOTS!!
A mother with which type of laceration should not receive rectal suppositories? a. 1st degree b. 2nd degree c. 3rd degree d. 4th degree e. both C&D
Answer: 4th Degree
A mother is 4 days postpartum, which type of lochia do you expect to find during your assessment? a. lochia serosa b. lochia rubra c. lochia alba d. no lochia
Answer: A
During a counseling session on natural family planning techniques, how should the nurse explain the consistency of cervical mucus at the time of ovulation? a. thin and elastic b. opaque and acidic c. increase in leukocytes to prevent infection d. decrease in quantity
Answer: A
A woman who wishes to use the calendar method of contraception, reports that her last 6 menstrual cycles were 28, 32, 29, 36, 30, and 27 days long. In the future, if used correctly, she should abstain from intercourse on which of the following days of her cycle? a. 9-25 b. 10-15 c. 11-20 d. 12-17
Answer: A Rationale: to calculate the period of abstinence using the calendar method, the nurse must substract (-) 18 from the shortest cycle and 11 from the longest cycle... 27-18 = 9 36-11 = 25
A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? a. the nurse measures the fundal height with a tape measure b. the nurse stabilizes the base of the uterus with his/her dependent hand c. the nurse palpates the fundus with the tips of his/her fingers
Answer: B
The nurse has taught a couple about the sympothermal method of natural family planning. Which of the following behaviors would indicate that the teaching was effective? a. the woman takes her temperature before bed every evening b. the couple charts information for at least 6 cycles before relying on the method c. the couple resumes intercourse as soon as they see a rise in BBT d. the woman assesses her vaginal discharge daily for changes in color and odor.
Answer: B
Ms. Pluto would like to conceive her first pregnancy. Which of the following is an essential component of preconception/internatal care? a. must achieve a normal BMI before conception b. must be off all hormonal contraception for one full year c. folic acid 0.4 mg/day four months prior to conception d. must be in an exercise program that involves 60 minutes of vigorous exercise per day
Answer: C
The nurse monitors her postpartum clients carefully because of the following physiological changes occurs during the early postpartum period? a. decreased urinary output b. increased blood pressure c. decreased blood volume d. increased estrogen level
Answer: C
You are assessing a woman 24 hrs after delivery and find that her fundus to be boggy and 2 cm above the umbilicu. What should be your priority nursing intervention? a. document this expected finding and check lochia b. assess the mother's vital signs c. after having the mother void, gently massage the fundus until firm d. notify the physician and document
Answer: C
A woman had a c-section yesterday. She states she needs to cough but is afraid to do so. Which of the following is the nurse's BEST response? a. "I know it hurts but it is important for you to cough" b. "Let me check your lungs to see if coughing is really necessary" c. "If you take a few deep breaths, that should be as good as coughing" d. "If you support your incision with a pillow, coughing should hurt less"
Answer: D
Ms. C experienced an NSVD 15 minutes ago. Where would you expect to find her fundus? a. 1 FB above umbilicus b. at umbilicus c. 1 FB below the umbilicus d. 2 FB below the umbilicus
Answer: D
You are aware that which of the following is a common factor that may interfere with the process of involution? a. the use of IV pain medication b. percipitus (fast) labor c. primipara d. over-distended bladder
Answer: D
What is uterine atony?
Answer: uterine muscles not contracting
What is Lochia?
Answer: vaginal discharge after delivery --> shedding or sloughing of decidua/lining of uterus