NUR 131 Exam 3 Study Guide
Nursing measures to maintain newborn's body temperature include:
- Drying them immediately after birth to prevent heat loss through evaporation - Wrapping them in prewarmed blankets - Putting a hat on their head - Placing them under a temperature-controlled radiant warmer - Skin-to-skin is also helpful as long as the person providing the skin to skin is preventing any drafts to the baby
Jaundice is a very common condition in newborns. What is the difference between physiologic and pathological jaundice? What are the risk factors for jaundice? What are the signs and symptoms of jaundice? Newborns undergoing phototherapy for jaundice require what kinds of assessment/care?
- Hyperbilirubinemia is an elevation of serum bilirubin levels resulting in jaundice - Jaundice normally appears in the head (especially the sclera and mucous membranes), and then progresses down the throax, abdomen, and extremities Physiologic jaundice is considered benign (resulting from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBC's and liver immaturity). The infant with physiological jaundice has no other symptoms and shows signs of jaundice after 24 hr of age. Pathologic jaundice is a result of an underlying disease. Pathologic jaundice appears before 24 hr of age or is persistent after day 7. In the term infant, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 13 mg/dL, or is associated with anemia and hepatosplenomegaly. Pathologic jaundice is usually caused by a blood group incompatibility or an infection, but may be the result of RBC disorders. Risk Factors: - Increased RBC production or breakdown Rh- or ABO-incompatibility - Decreased liver function - Ineffective breastfeeding - Sibling with diagnosed jaundice - Certain medications (maternal ingestion of aspirin, tranquilizers, and sulfonamides) - Hypoglycemia - Hypothermia - Anoxia - Prematurity Physical Assessment Findings: - Note yellowish tint to skin, sclera, and mucous membranes - To verify jaundice, press the infant's skin on the cheek or abdomen lightly with one finger. Then, release pressure and observe the infant's skin color for yellowish tint as the skin is blanched - Note the time of jaundice onset to distinguish between physiologic and pathologic jaundice - Assess the underlying cause by reviewing the maternal prenatal, family, and newborn history - Signs of hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can occurs as a result of hyperbilirubinemia and may increase the risk of brain damage Nursing Care: - Observe the infant's skin and mucous membranes for signs of jaundice - Monitor the infant's vital signs - Set up phototherapy as ordered - Maintain an eye mask over the newborn's eyes for protection of corneas and retinas - Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (make like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves - Avoid applying lotions or ointments to the infant because they absorb heat and can cause burns - Remove the newborn from phototherapy every 4 hr and unmask the newborn's eyes, checking for signs of inflammation or injury - Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores
Match the terms in Column A with their description in Column B. Column A 1. Bonding 2. Proximity 3. Process of attachment 4. Postpartum blues Column B A. Physical and psychological experience of the parents being close to their infant B. Transient emotional disturbances C. Development of a close emotional attachment to a newborn by the parents during the first 30 to 60 minutes after birth D. Development of strong affectional ties between an infant and a significant other (e.g., mother, father, sibling, caretaker)
1. - C 2. - A 3. - D 4. - B
Matching A. Conduction B. Convection C. Evaporation D. Radiation 1. __________ involves the loss of heat when a liquid is converted to a vapor. Loss may be insensible (from skin and respiration) or sensible (from sweating). 2. __________ involves the transfer of heat from one object to another when the two objects are in direct contact with each other. 3. __________ involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. 4. __________ involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface.
1. - C 2. - A 3. - D 4. - B
Match the terms in Column A with their descriptions in Column B. Column A 1. Engrossment 2. Involution 3. Lochia 4. Puerperium 5. Uterine atony Column B A. The discharge that occurs after birth B. Encompasses the time after delivery as the woman's body begins to return to the prepregnant state C. Allows excessive bleeding D. The father's developing a bond with his newborn, which is a time of intense absorption, preoccupation, and interest E. Involves three retrogressive processes, which are contraction of muscle fibers, catabolism, and regeneration of uterine epithelium
1. - D 2. - E 3. - A 4. - B 5. - C
The red blood cells of a newborn have a life span of 80 to __________ days.
100
The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? Select all that apply A. Have the mother nap before interacting with her newborn B. Dim the lights in the birthing room C. Place the newly delivered infant on the mother's abdomen D. Delay instilling the ophthalmic antibiotic for an hour E. Play loud music to keep the infant stimulated F. Ask the parents to delay phone calls for an hour after birth
2, 3, 4, 6 1. If the mother naps immediately after birth, the alert newborn period may be missed 2. Dimming the lights in the birthing room encourages the newborn to open his or her eyes. This in turn encourages eye contact between the parent and the newborn 3. Skin-to-skin contact between mother and baby at birth improves mother-baby interaction 4. Instillation of ophthalmic antibiotic ointment should be delayed for an hour because instilling it now may cause temporary blurred vision in the newborn. The temporary blurred vision can decrease the infant's ability to engage in eye-to-eye contact with the parents, thus affecting parent-infant attachment 5. Avoiding loud noises encourages parent-infant communication 6. The newborn is alert for up to 1 hour after birth. Parents should be encouraged to use this time for attachment and to delay phone calls
Low birth weight is defined as less than __________ g.
2,500
A mother choosing to breast-feed or lactate requires an additional __________ calories per day.
500
The nurse is assessing the client newly diagnosed with endometrial cancer. Which common findings would the nurse expect? A. Abnormal vaginal bleeding and pain in the pelvic area B. Weight loss and profuse sweating, especially at night C. Anorexia and enlarged supraclavicular lymph nodes D. Unexplained spikes in temperature and splenomegaly
A 1. Abnormal vaginal bleeding and pain in the pelvic region appear as the most common presenting symptoms in the client with endometrial cancer 2. Weight loss is not a common presenting symptom unless the cancer is advanced. Night sweats may occur with hormone changes 3. Supraclavicular lymph nodes are located just above the clavicle, lateral to where it joins the sternum, and not near the uterus 4. Unexplained temperature spikes and splenomegaly are not common presenting symptoms
A nurse is instructing a client about breast-feeding. Which instructions should she include to help prevent the client from developing mastitis? Select all that apply A. Wash hands before handling the breast and breast-feeding B. Change the breast pads frequently C. Expose the nipples to air for part of each day D. Wash the nipples with soap and water E. Make sure that the neonate grasps the nipple only F. Release the neonate's grasp on the nipple before removing him from the breast
A, B, C, F What is Mastitis? - Plugged milk duct / infrequent feeding - Infection Assessment: - Warm, tender hardened area on breast - Chills, fever, headache, malaise Interventions: - ABX - Increase fluid intake - Pump after feeding to ensure breast empty - Warm compress or ice for comfort Teaching: - Because mastitis is an infection frequently associated with a break in the skin surface of the nipple, measures to prevent cracked and fissured nipples help prevent mastitis - Changing breast pads frequently and exposing the nipples to air for part of the day help keep the nipples dry and prevent irritation - Washing hands before handling the breast reduces the change of accidentally introducing organisms into the breast - Releasing the neonate's grasp on the nipple before removing him from the breast also reduces the chance of irritation - Nipples should be washed with water only; soap tends to remove the natural oils and increases the chance of cracking - The neonates should grasp the nipple and areola - Continue breast feeding or pumping
A nurse is completing postpartum discharge teaching to a client who had no immunity to rubella and was given a measles, mumps, and rubella (MMR) vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 1-3 months before considering getting pregnant again" B. "I need a second vaccination at my postpartum visit" C. "I was given the vaccine because my baby is O-positive blood type" D. "I will be tested in 3 months to see if I have developed immunity"
A. "I will need to use contraception for 1-3 months before considering getting pregnant again"
When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering
A. Bradycardia Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
A nurse in a newborn nursery receives a phone call to prepare for the admission for a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5C (97.6F)
A. Connect the resuscitation bag to the oxygen outlet The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
A nurse is assessing a newborn infant following a circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action would be most appropriate? A. Document the finding B. Contact the physician C. Circle the amount of drainage and reassess in 30 minutes D. Reinforce the dressing
A. Document the finding The penis is usually red during the healing process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. Because the findings identified in the question are normal, the nurse would document the assessment.
A nurse knows that maintaining a newborn's axillary body temperature between 97.7 (36.5 C) and 99.5 (37.5 C) is an appropriate outcome. To accomplish this outcome the nurse should: Select all that apply A. Dry the infant immediately after birth B. Place the infant skin to skin with the mother C. Apply leggings to the infant's legs D. Cover the infant's head with a stocking cap E. Place the infant in a crib close to the delivery room wall F. Wrap the infant in warm blankets and place him under a radiant heat source
A. Dry the infant immediately after birth B. Place the infant skin to skin with the mother D. Cover the infant's head with a stocking cap - Drying the new born immediate;y after birth prevents heat loss through evaporation. Skin-to-skin contact assists to maintain newborn body temperature. Head is dried first and a stocking cap placed to conserve heat. - Wrap baby in warmed blankets to reduce heat loss via convection (from body surface to cooler temp) - Avoid placing by wall to prevent loss through radiation (loss of body heat to cooler solid surfaces not in direct contact) Thermoregulation: - Normal temp: 97.7 - 99.5 - If 97.5 - place skin-to-skin on mother - - - Warm by 1/2 - 1 degress - - - Help maintain temperatue - - - Promotes breastfeeding and bonding - If full degree below normal - - - Place under radiant warmer - radiant heat warms outer surface of objects (least amount of clothes to get benefit) - Cold stress - - - Metabolic acidosis - - - Respiratory distress - oxygen consumption increases / increased RR - - - Hypoglycemia, increased activity level, crying Normal Vital Signs: - Resp: 30-60 with apneic episodes of 5-10 seconds (will increase with crying) - Pulse: 110-160 - Pink body / blue extremities (acrocyanosis) - - - Due to transition to extrauterine life - progression of cardiac perfusion to extremities - - - Up to 24 hours of life - Weight loss: normal is 5-10% Aspiration of the neonates mouth then nose with bulb syringe happens immediately following birth to maintain the airway
A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: A. Encourage rotating breast-feeding positions with each feeding B. Stop nursing until the nipples heal C. Substitute a bottle-feeding until the nipples heal D. Wash nipples and areola with soap and warm water after each feeding
A. Encourage rotating breast-feeding positions with each feeding
Why do women who have had cesarean births tend to have less flow of lochial discharge?
Women who have had cesarean births tend to have less flow because the uterine debris is removed manually with delivery of the placenta
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours
A. Monitoring for the passage of meconium each shift Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6 degrees F. The physician suspects infection and writes orders to treat the client. Which of the following orders written by the physician would the nurse complete first? A. Obtain culture and sensitivity of lochia and urine B. Administer Ceftriaxone (Rocephin) C. Check the client's temperature D. Increase the intake of oral fluids
A. Obtain culture and sensitivity of lochia and urine
A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include? A. The diet should include additional fluids B. Prenatal vitamins should be discontinued C. Soap should be used to cleanse the breasts D. Birth control measures are unnecessary while breast-feeding
A. The diet should include additional fluids
A nurse is caring for a client who has just delivered a healthy baby girl. The client is aware of the benefits of breastfeeding. She expresses her desire to breastfeed her newborn. 1. What assessments should the nurse perform in this regard? 2. How often should the client breastfeed her infant during the postpartum period?
A. The nurse should perform the following assessments in a client intending to breastfeed her baby: - Inspect the breasts for size, contour, asymmetry, engorgement, or areas of erythemia - Check the nipples for cracks, redness, fissures, or bleeding - Palpate the breasts to ascertain if they are soft, filling, or engorged, and document findings - Palpate the breasts for any nodules, masses, or areas of warmth, which may indicate a plugged duct that may progress to mastitis if not treated promptly - Describe and document any discharge from the nipple that is not creamy yellow or bluish white B. The client is encouraged to offer frequent feedings, at least every 2 to 3 hours, using manual expression just before feeding to soften the breast so the newborn can latch on more effectively. The client should be told to allow the newborn to feed on the first breast until it softens before switching to the other side
A nurse is caring for two clients, one who is breastfeeding and has developed breast engorgement, and another who is not breastfeeding and has developed breast engorgement. 1. What relief measures should the nurse suggest to resolve engorgement in the client who is breastfeeding? 2. What relief measures should a nurse suggest for non-breastfeeding engorgement?
A. The nurse should suggest the following measures to resolve engorgement in the client who is breastfeeding: - Empty the breasts frequently to minimize discomfort and resolve engorgement. Stand in a warm shower or apply warm compresses to the breasts to provide some relief B. The nurse should suggest the following relief measures for the client with non-breastfeeding engorgement: - Wear a tight, supportive bra 24 hours daily - Apply ice to the breasts for approximately 15 to 20 minutes every other hour - Do not stimulate the breasts by squeezing or manually expressing milk from the nipples - Avoid exposing the breasts to warmth
When providing care to postpartum patients, the nurse assesses a patient with an approximate 750 ml blood loss in the first 12 hours after a vaginal delivery of a baby with a weight of 9lbs 2oz. What does the nurse consider as the most likely cause for blood loss in the postpartum patient? A. Uterine atony B. Perineal laceration C. Retained placental fragments D. DIC
A. Uterine atony
A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? Select all that apply. A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D. Continue to breast-feed if the breasts are not too sore E. Take the prescribed antibiotics until the soreness subsides F. Avoid decompression of the breasts by breast-feeding or breast pump
A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D. Continue to breast-feed if the breasts are not too sore
Hypercapnia, hypoxia, and __________ resulting from normal labor become the stimuli for initiating respirations in the newborn.
Acidosis
Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness is called __________.
Acrocyanosis
__________ are the painful uterine contractions some women experience during the early postpartum period.
Afterpains
__________ refers to the uterine contractions that occur after birth.
Afterpains
Why are afterpains more acute in multiparous women?
Afterpains are more acute in multiparous women secondary to repeated stretching of the uterine muscles, which reduces muscle tone, allowing for alternate uterine contraction and relaxation.
What can you teach your postpartum patient about contractions after delivery?
Afterpains are normal and can be worse when breastfeeding and also stronger in multiparous patients. Teaching mom about fundal massage and pain medications to relieve the pain is helpful
Why are afterpains usually stronger during breastfeeding? What can be done to reduce this discomfort?
Afterpains are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Mild analgesics can be used to reduce this discomfort
Lochia __________ occurs from postpartum days 10 to 14.
Alba
The __________ fontanel of the baby is diamond shaped and closes by age 18 to 24 months.
Anterior
Mastitis is treated with oral __________ and acetaminophen.
Antibiotics
The __________ score is used to evaluate newborns at 1 minute and 5 minutes after birth.
Apgar
Jane ^ Assess, Do, Teach?
Assess - Temperature - Pulse - Pain - Lochia - Wound - Lab tests (WBC, sedimentation rates) - Blood - Lochia - Wound - Urine cultures Do - Wound care, aseptic techniques / hand washing - Comfort measures - Administer antibiotic, analgesics, antipyretics as ordered Teach - Standard precaution - Signs & symptoms to report - Prevention: adequate rest & nutrition (> Vitamin C, protein), proper breastfeeding techniques - Follow antibiotic therapy
The development of strong affectional ties between an infant and significant other defines the process of __________.
Attachment
The nurse is preparing for beginning of shift rounds on assigned postpartum clients. After reviewing the assignment, the nurse plans to assess for hematoma formation in which client, who is at greatest risk for this complication? A. A 17-year old client who gave birth to a small-for-gestational-age infant B. A 26-year old client with gestational diabetes and forceps delivery of a large-for-gestational-age infant C. A 35-year old client having twins D. A 40-year old client having her first infant
B What is a hematoma? - A collection of blood in the pelvic tissue cause by damage to the blood vessel wall without laceration Risk factors include: - LGA - Forceps delivery Assessment: - Discoloration or bulging of tissue at hematoma site - Perineal pain - intense and disproportionate - Closely inspect / re-inspect perineum Interventions: - Ice to perineum - Analgesics - Sitz baths - May require drainage by MD
Lochia refers to the discharge that occurs after birth. Given below, in random order, are the three stages of lochia. Choose the correct sequence in which they appear after birth. A. Lochia alba B. Lochia rubra C. Lochia serosa
B - > C - > A
The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn's father? A. Talks to his newborn from across the room B. Shows similarities between his and the baby's ears C. Expresses feeling frustrated when the infant cries D. Seems to be hesitant to touch his newborn
B - > Engrossment us demonstrated by the father touching the infant, making eye contact with the infant, verbalizing awareness of features in the newborn that are similar to his and that validate his claim to that newborn Not making face to face contact = lack of engrossment Frustration is common in the second stage (reality)
Which clinical finding is most suggestive of physiologic hyperbilirubinemia in a neonate? A. Clinical jaundice before 24 hours of age B. Bilirubin levels of 10 mg/dl 3 days after birth C. Clinical jaundice lasting beyond 14 days D. Serum bilirubin level increasing by more than 5 mg/dl/day
B - Physiological Jaundice - 24-48 hours after birth (3rd-4th day of life) - With hyperbilirubinemia, increased bilirubin levels in the neonate's live usually cause bilirubin levels of 10 mg/dl by day 3 of life - This is from the impaired conjugation and excretion of bilirubin and difficulty clearing bilirubin from plasma Early onset breast feeding jaundice: - Associated with ineffective breast feeding / delayed meconium defecation Late onset breast feeding jaundice: - Level peaking at 6-14 days related to change in milk composition Pathological jaundice - Within first 24 hours of age or lasting beyond 14 days - Serum bilirubin level that increases more than 5 mg/dl/day - Cause: sepsis, Rh incompatibility, ABO incompatibility Risk factors: - Cephalhematoma (collection of blood between skull and periosteum / does not cross suture line), preterm infants, poor feeding, polycythemia, inadequate breast feeding, east Asian/American Indian/Mediterranean descent Assessment: - Yellow tinged to skin / sclera - descending (starts at head moves down) - Pressure on forehead - evaluate color once pressure removed - Assess neuro status, eating, peeing/pooping (that is how excreted), excessive bruising Intervention: - Increase feeding frequency / support adequate breast feeding - Place in window for sunlight - Phototherapy if severe Nursing care: - Support bonding, place infant on back (lots of skin exposed), eye care / protection, check temperature, skin care, daily weights - Exchange transfusion (if remain elevated after intensive phototherapy) - Removes newborn blood and replace with donor's blood
A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor determines that he student needs to research this procedure further if the student states: A. "I will cleanse the neonate's eyes before instilling ointment" B. "I will flush the eyes after instilling the ointment" C. "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth" D. Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur"
B. "I will flush the eyes after instilling the ointment" Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation
B. Convection Convection heat loss is the flow of heat from the body surface to the cooler air.
While assessing a 2-hour old neonate, the nurse observes the neonates to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn's temperature according to hospital policy D. Notify the physician of the need for a cardiac consult
B. Do nothing because acrocyanosis is normal in the neonate Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.
A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in the care of the client? A. Providing sitz baths B. Encouraging fluid intake C. Placing ice on the perineum D. Monitoring hemoglobin and hematocrit levels
B. Encouraging fluid intake
At which of the following locations would the nurse expect to palpate the fundus of a primiparous client an hour after birth of a neonate? A. Above the level of the umbilicus B. Halfway between the umbilicus and the symphysis pubis C. Just below the level of the umbilicus D. At the level of the umbilicus
B. Halfway between the umbilicus and the symphysis pubis - Immediately after delivery of the placenta, the nurse would expect to palpate the fundus halfway between the umbilicus and the symphysis pubis - 6-12 hours postpartum, the fundus should be palpated at the level of the umbilicus - If it us above the level of the umbilicus - abnormal finding and needs to be investigated - After the first 12 hours, the fundus should decrease one fingerbreadth (1 cm) per day in size. By the 10-14 day, the fundus usually is no longer palpable What is the normal PP assessment? - Breasts: inspect nipples, breast tissue, color - Fundus: firm, midline - if soft; massage fundus in circular motion / if displaced have client empty bladder - Bladder: time of last void / color, odor, amount - Bowels: last BM - Lochia: color, amount, presence of clots - - - Ask when last changed pad - - - Rubra - serosa - alba - - - Scant, small, moderate, heavy - Incision / episiotomy: type, tissue, trauma, redness - - - Ice to perineum - Legs (Homans Sign): pain varicosities, pedal pulses - Emotions: affect, pt/family interaction - Bonding: "taking-in" phase - gazing, enfolding, calling by name - - - Allow client to talk about experience Normal Lab Values: - WBC: 12-13,000 (elevated during 3rd trimester and stays elevated postpartum - HCT: 34-46 - HGB: 12-16 - Vital Signs: 100.4 / 50-70 (first 6-10 days) Teaching: - Supportive bra to help with breast engorgement - Warm water to help with let down - Check fundus several times a day - Notify MD of foul smelling lochia / heavy bleeding - 2-3 days before normal BM
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Large lochia rubra C. Light lochia rubra D. Scant lochia serosa
B. Large lochia rubra
The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. Setting up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence
B. Showing by example and explanation how to care for the infant Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace
Reflexes: Babinski Blinking Grasping Moro Rooting Stepping Sucking Tonic neck
BABINSKI Stimulation - Sole of foot stroked Response - Fans out toes and twists foot in Duration - Disappears at nine months to a year BLINKING Stimulation - Flash of light or puff of air Response - Closes eyes Duration - Permanent GRASPING Stimulation - Palms touched Response - Grasps tightly Duration - Weakens at three months; disappears at a year MORO Stimulation - Sudden move; loud noise Response - Startles; throws out arms and legs and then pulls them toward body Duration - Disappears at three to four months ROOTING Stimulation - Cheek stroked or side or mouth touched Response - Turns toward source, opens mouth and sucks Duration - Disappears at three to four months STEPPING Stimulation - Infant held upright with feet touching ground Response - Moves feet as if to walk Duration - Disappears at three to four months SUCKING Stimulation - Mouth touched by object Response - Sucks on object Duration Disappears at three to four months TONIC NECK Stimulation - Placed on back Response - Makes fists and turns head to the right Duration - Disappears at two months
__________, an alternative to radiation therapy, involves the use of a catheter to implant radioactive seeds into the breasts after a tumor has been removed surgically.
Brachytherapy
Given below, in random order, are the three stages a woman goes through immediately after she gives birth to a child. Choose the correct sequence in which they occur. A. Letting-go phase B. Taking-hold phase C. Taking-in phase
C - > B - > A
A nurse prepares to administer a Vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "Your infant needs Vitamin K to develop immunity" B. "The Vitamin K will protect your infant from being jaundiced" C. "Newborn infants are deficient in Vitamin K and this injection prevents abnormal bleeding" D. "Newborn infants have sterile bowels, and Vitamin K promotes the growth of bacteria in the bowel"
C. "Newborn infants are deficient in Vitamin K and this injection prevents abnormal bleeding" Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent bleeding. Newborn infants are Vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat soluble Vitamin K. The infant's bowel does not support the production of Vitamin K until bacteria adequately colonizes it by food ingestion.
A nurse is assessing a newborn at birth to assign Apgar scores. At 1 minutes of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. The newborns trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A. 7 B. 8 C. 9 D. 10
C. 9 A maximum score of 2 is given for each parameter - this infant lost 1 point for the acrocyanosis What is our nursing intervention? - An Apgar score 8-10: no intervention needed. Maintain normal respiratory efforts and maintain thermoregulation - An Apgar score of 4 to 7 (out of a total possible score of 10) indicates moderate respiratory depression. To correct this problem, the nurse should stimulate breathing by rubbing the neonate's back or by gently but firmly slapping the neonate's soles. The nurse should also provide oxygen (at 100% concentration) but should administer it by bag and face mask rather than nasal prongs - The nurse should perform CPR only if the neonate's Apgar score is between 0 and 3. The neonate must be stabilized before being held by the mother Why score at 1 and 5 minutes? - 1 minute assessment of initial adaptation to extrauterine life - 5 minutes provides a clearer indication of overall nervous system status A = appearance (color) P = pulse (heart rate) G = grimace (reflex irritability) A = activity (muscle tone) R = respiratory (respiratory effort) Each parameter is assigned a score ranging from 0 to 2 points. A score of 0 points indicates an absent or poor response; a score of 2 points indicates a normal response
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, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow
C. A normal postural discharge of lochia
On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following: A. Call the physician B. Assess the client's vital signs C. Gently massage the uterine fundus D. Administer a 300 ml bolus of a 20 units/L Oxytocin (Pitocin) solution
C. Gently massage the uterine fundus
Which of the following most characterizes endometrial cancer? A. Dyspareunia B. Thickened endometrial lining C. Irregular menstrual bleeding D. Low blood pressure
C. Irregular menstrual bleeding Endometrial cancer arises from the lining of the uterus. The first sign is abnormal bleeding. Painful intercourse is a symptom along with painful urination. It typically occurs after menopause
__________ is a localized effusion of blood beneath the periosteum of the skull of the newborn.
Cephalhematoma
__________ cancer is more common in pregnant women than other reproductive malignancies.
Cervical
Papanicolaou smear (Pap smear) is usually done to determine cancer of what?
Cervical Cancer
What is the recommended screening tests for the following? Cervical Cancer Ovarian Cancer Breast Cancer
Cervical Cancer - Annual pap smear - HPV test Ovarian Cancer - CA 125 blood test - Intravaginal ultrasound - Pelvic exam Breast Cancer - Mammogram every 1-2 years - Clinical breast exam annually by a provider - Breast self exam monthly, one week after menses
Women who experience __________ births will have less lochia discharge than those having a vaginal birth.
Cesarean
__________, a type of therapy for breast cancer, leads to side effects such as hair loss, weight loss, and fatigue.
Chemotherapy
Congenital fissure or longitudinal opening in the lip
Cleft Lip
Any discharge from the nipple should be described and documented if it is not __________, or foremilk.
Colostrum
__________ refers to the enduring nature of the attachment relationship.
Commitment
__________ involves the transfer of heat from one object to another when the two are in direct contact with each other.
Conduction
__________ occurs when the posterior bladder wall protrudes downward through the anterior vaginal wall.
Cystocele
A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? A. "I need to take antibiotics, and I should begin to feel better in 24-48 hours" B. "I can use analgesics to assist in alleviating some of the discomfort" C. "I need to wear a supportive bra to relieve the discomfort" D. "I need to stop breastfeeding until this condition resolves"
D. "I need to stop breastfeeding until this condition resolves" Keep breast pads clean and dry by changing often; continue to feed from both breasts
The postpartum nurse who is reviewing the client assignment determines that which client is at greatest risk for primary (early) postpartum hemorrhage? A. A client with an infant weighing 5 pounds 7 ounces B. A client who is 17 years old C. A client with endometriosis D. A client with uterine atony
D. A client with uterine atony Uterine atony accounts for majority of early (within first 24 hours) hemorrhage - fundal massage What are other risk factors for early PP hemorrhage? - Cervical lacerations - firm fundus, continuous trickle of bright red blood - notify health care provider - Larger for gestation babies - uterine atony - over distended uterus / boggy - Retained placental tissue - boggy uterus - Ruptured uterus Risk factors for late PP hemorrhage? (24 hours - 6 weeks post birth) - Uterine infection - Endometritis - foul smelling lochia, uterine tenderness - abx / treat symptoms - Subinvolution - boggy fundus / higher than normal / heavy discharge - Retained placental tissue - boggy uterus Assessment for PPH: - Restlessness, LOC, vague complaints - Increase pulse / decrease BP - Bleeding - describe / amount - Uterus - firm or boggy
The nurse is collecting information for assessing a woman at her 6 week postpartum appointment. Which of the following does the nurse anticipate the patient reporting for current lochia? A. Lochia rubra B. Lochia serosa C. Lochia alba D. Absence of lochia
D. Absence of lochia
The nurse is working with a postpartum mom after delivery. Which behavior would the nurse expect to assess during the taking in phase of the couplet? A. Frequent infant care questions B. Adapting to parent role C. Encouraging own self-car D. Contemplating thoughts on labor
D. Contemplating thoughts on labor
A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-3 hours
D. Continue to breastfeed every 2-3 hours Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It's a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head
D. It involves swelling of tissue over the presenting part of the presenting head Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.
Neonates of mother with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothroax D. Macrosomia
D. Macrosomia Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increased in fetal insulin.
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5 F, a respiratory rate of 80 breaths/minute, and a heel stick glucose of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open crib B. Administer an oral glucose feeding of 10% dextrose in water C. Increase the temperature setting on the radiant warmer D. Obtain an order for IV fluid administration
D. Obtain an order for IV fluid administration Assessment findings indicate that the neonate is in respiratory distress - most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breathes a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix
D. Vernix
The profuse __________ that is common during the early postpartum period is one of the most noticeable adaptations in the integumentary system and is a way of eliminating excess body fluids retained during pregnancy.
Diaphoresis
Severe anomaly of failure in the development of the diaphragm that results in an abnormal insertion onto the inner chest wall
Diaphragmatic Hernia
Cervical __________ is the precursor to cervical cancer.
Dysplasia
A nurse is preparing to conduct a women's wellness seminar at a local civic center. What information should the nurse plan to include about risk factors for development of breast cancer? Select all that apply A. Breast cancer occurs most frequently in women younger than 30 years old B. The longer the interval between menarche and menopause, the more the risk increases C. Nulliparous women are at increased risk D. Risk is increased in postmenopausal women with body mass index below 20 E. Women whose sisters or mothers have had breast cancer are at increased risk F. The risk factors for women with fibrocystic breast disease
Early menarche and/or late menopause increase the risk of developing breast cancer. Childless women are at increased risk as are women with first degree relatives who had breast cancer. BRCA 1 and BRCA 2 Assessment: - Usually detected as a single lump or mammographic abnormality in breast - Rate of growth of lesion varies - Very small percentage cause nipple discharge - If palpable: often hard, irregularly shaped, poorly delineated, nonmobile, nontender - Usually occur in the upper outer quadrant - May have nipple retraction - May have skin thickening and exaggeration of skin markings (orange peel - peau d'orange) Interventions: - Early detection - breast exams, mammography - Surgical procedures - Medications Teaching: - Breast self exams, risk factors, procedures, medications, chemo, radiation - Breast exam: using pads of fingers in circular motion
Increased prolactin levels and abundant milk supply, combined with inadequate emptying of the breast, may cause breast __________.
Engorgement
__________ or swelling of the breast tissue occurs usually 2 to 4 days after birth.
Engorgement
Breast cancer starts in the __________ cells that line the mammary ducts within the breast.
Epithelial
Most ovarian cancers originate in the ovarian __________.
Epithelium
Hormone therapy is used to block or counter the effect of the hormone __________ while treating breast cancer.
Estrogen
Fathers or partners go through three stages in their role development process: __________, reality, and transition to mastery.
Expectations
What are the factors that facilitate uterine involution?
Factors that facilitate uterine involution are - Complete expulsion of amniotic membranes and placenta at birth - Complication-free labor and birth process - Breastfeeding - Ambulation
What are the factors that inhibit involution?
Factors that inhibit involution include - Prolonged labor and difficult birth - Incomplete expulsion of amniotic membranes and placenta - Uterine infection - Overdistention of uterine muscles due to ----- Multiple gestation, hydramnios, or large singleton fetus ----- Full bladder, which displaces uterus and interferes with contractions ----- Anesthesia, which relaxes uterine muscles ----- Close childbirth spacing, leading to frequent and repeated distention and thus decreasing uterine tone and causing muscular relaxation
A finger-stick blood sample is used to assess a newborn's blood glucose level.
False
A woman typically experiences tachycardia after delivery.
False
Cardiac output quickly returns to nonpregnant values after birth.
False
During the first 24 hours postpartum, heat is used to provide perineal comfort.
False
Fibrocystic breast changes are most common in women under the age of 30 years.
False
In general, the first treatment option for woman diagnosed with breast cancer is hormonal therapy.
False
In most cases, a mass on an ovary after menopause is a cyst.
False
Lochia typically begins as lochia serosa.
False
Screening for endometrial cancer is routinely performed.
False
The newborn's respiratory rate typically ranges from 15 to 30 breaths per minute.
False
The postpartum period begins with the birth of the newborn.
False
The umbilical vessels disappear after birth.
False
The woman with breast cancer usually experiences lumpy, tender breasts during the week before menses.
False
Nasal flaring in the newborn infant is an expected finding.
False In the newborn, nasal flaring indicates the infant is experiencing a problem with transition to extrauterine life.
An extremely low birth weight newborn weighs less than 2,500 g.
False The extremely low birth weight infant weighs less than 1,000 g.
A newborn's chest circumference is usually 1 to 2 cm larger than the head circumference.
False The newborn's chest circumference is generally 1 to 2 cm smaller than the head circumference.
A comprehensive assessment of the newborn should occur immediately after birth.
False Immediately after birth a rapid assessment is performed to determine the newborn's stability. After the newborn has successfully completed transition, the comprehensive assessment will be performed.
__________ are common benign solid breast tumors occuring in about 10% of all women and accounting for up to half of all breast biopsies.
Fibroadenomas
__________ are common benign solid breast tumors that occur in about 10% of all women and account for up to half of all breast biopsies.
Fibroadenomas
The top portion of the uterus, known as the __________, is assessed to determine uterine involution.
Fundus
Anomaly of the anterior abdominal wall
Gastroschisis
APGAR SCORING - Explain how assessed and parameters Assessment: Heart Rate Respiratory Rate Muscle Tone Reflex Irritability Skin Color
HEART RATE: Auscultation of apical heart rate for full minute - Absent = 0 Points - Slow (<100 bpm) = 1 Point - >100 bpm = 2 Points RESPIRATORY RATE: Observation of the volume and vigor of the newborn's cry, auscultation of depth & rate of respirations - Apneic = 0 Points - Slow, irregular, shallow = 1 Point - Regular respirations (usually 30-60 breaths/min), strong, good cry = 2 Points MUSCLE TONE: Observation of extent of flexion in the newborn's extremities and newborn's resistance when the extremities are pulled away from the body - Limp, flaccid = 0 Points - Some flexion, limited resistance to extension = 1 Point - Tight flexion, good resistance to extension with quick return to flexed position after extension = 2 Points REFLEX IRRITABILITY Flicking of the soles of the feet or suctioning of the nose with a bulb syringe - No response = 0 Points - Grimace or frown when irritated = 1 Point - Sneeze, cough, or vigorous cry = 2 Points SKIN COLOR Inspection of trunk and extremities with the appropriate color for ethnicity appearing within minutes after birth - Cyanotic or pale = 0 Points - Appropriate body color; blue extremities (acrocyanosis) = 1 Point - Completely appropriate color (pink on both trunk and extremities) = 2 Points
__________ sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of paleness on one side of the body and ruddiness on the other.
Harlequin
If the postpartum patient's uterus is boggy and deviated to the right, what would the nurse do next after massaging the uterus?
Have the patient get up and void then when she returns to bed, reassess the fundus for location and firmness. If the uterus is still boggy, massage
When diagnosing a woman with intraductal papiloma, a __________ card is used to evaluate nipple discharge for the presence of occult blood.
Hemocult
Methergine has been ordered for a postpartum patient with excessive bleeding. What condition would alert the nurse to hold this medication?
High blood pressure; PIH (pregnancy induced hypertension and/or preeclampsia)
Increase in CSF in the ventricles of the brain due to overproduction or impaired circulation and absorption
Hydrocephalus
Elevations in blood pressure from the woman's baseline might suggest pregnancy-induced __________.
Hypertension
Malformation of the male genitalia
Hypospadias
A woman who is bottle-feeding should use __________ packs to alleviate the discomfort of engorgment.
Ice
__________ is used as an adjunct therapy for breast cancer.
Immunotherapy
The uterus returns to its normal size through a process called __________.
Involution
__________ exercises help to strengthen the pelvic floor muscles.
Kegel
__________ exercises strengthen the pelvic floor muscles to support the inner organs and prevent further prolapse.
Kegel
__________ is the secretion of milk by the breasts.
Lactation
__________ refers to the soft, downy hair on the newborn's body.
Lanugo
Babies weighing more than the 90th percentile on standard growth charts are referred to as __________ for gestational age.
Large
Uterine fibroids, or __________, are benign proliferations composed of smooth muscle and fibrous connective tissue in the uterus.
Leiomyomas
__________ is contraindicated for women whose active connective tissue conditions make them especially sensitive to the side effects of radiation.
Lumpectomy
Vulvar cancer is usually found on the labia __________.
Majora
__________ involves taking x-ray pictures of the breasts while they are compressed between two plastic plates.
Mammography
The removal of all breast tissues, the nipple, and the areola for breast cancer treatment is known as __________.
Mastectomy
Palpate the breasts for any nodules, masses, or areas of warmth, which may indicated a plugged duct that may progress to __________ if not treated promptly.
Mastitis
__________ is the thick, tarry, sticky, dark green stool passed within the first 48 hours after birth.
Meconium
Define menopause. What signs and/or symptoms would we assess in a menopausal patient? What nursing interventions would we implement?
Menopause is complete cessation of menstruation for one year. Signs and symptoms - Hot flashes - Palpitations - Diaphoresis - Osteoporosis Nursing interventions - Assessing psychological response - Discussing estrogen therapy including preventing osteoporosis and heart disease - Discussing alternate therapies to try (diet, exercise, calcium supplements)
Tumor staging is done to determine if the tumor has __________.
Metastasized
__________, or irregular, acyclic uterine bleeding, is the most frequent clinical manifestation of women with endometrial polyps.
Metrorrhagia
A condition in which a small brain is located within a normal-sized cranium
Microcephaly
__________ are unopened sebaceous glands frequently found on a newborn's nose.
Milia
Explain the difference between: Head molding Caput succedaneum Cephalahematoma.
Molding - The elongated shaping of the fetal head to accommodate passage through the birth canal Caput Succedaneum - Localized edema on the scalp that occurs from the pressure of the birth process - Commonly observed after prolonged labor - Soft tissue swelling that crosses the suture lines Cephalhematoma - Localized effusion of blood beneath the periosteum of the skull - Caused by disruption of the vessels during birth commonly caused by prolonged labor and the use of obstetric interventions such as forceps and vacuum extraction - Does not cross the suture line
The __________ reflex is also called the embrace reflex.
Moro
The nurse is assessing the lochia on a 1 day postpartum patient. The nurse notes that the lochia is red and has a foul smelling odor. What should the nurse be suspicious of with this patient's assessment?
Most likely is infection
The __________ period is defined as the first 28 days of life.
Neonatal
For __________ women, menstruation usually resumes 7 to 9 weeks after giving birth.
Nonlactating
__________ hypotension can occur when the woman changes rapidly from a lying or sitting position to a standing one.
Orthostatic
__________ acts so that milk can be ejected from the alveoli to the nipple.
Oxytocin
__________ is considered the fifth vital sign.
Pain
Within 10 days of birth, the fundus of the uterus usually cannot be palpated because it has descended into the true __________.
Pelvis
The __________ is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.
Peribottle
A __________ is a silicone or plastic device that is placed into the vagina to support the uterus, bladder, and rectum as a space-filling device.
Pessary
__________ are small benign growths that may be associated with chronic inflammation, an abnormal local response to increased levels of estrogen, or local congestion of the cervical vasculature.
Polyps
The __________ fontanel is triangular.
Posterior
Tumors in the vagina commonly occur on the __________ wall.
Posterior
__________ babies are babies with placental aging who are born after 42 weeks.
Postmature
What does the postpartum assessment of the mother include?
Postpartum assessment of the mother typically includes vital signs, pain level, and a systematic head-to-toe review of the body systems: breasts, uterus, bladder, bowels, lochia, episiotomy/perineum, extremities, and emotional status.
What are the postpartum danger signs?
Postpartum danger signs include - Fever more than 38 C (100.4 F) after the first 24 hours following birth - Foul-smelling lochia or an unexpected change in color or amount - Visual changes, such as blurred vision or spots, or headaches - Calf pain experiences with dorsiflexion of the foot - Swelling, redness, or discharge at the episiotomy site - Dysuria, burning, or incomplete emptying of the bladder - Shortness of breath or difficulty breathing - Depression or extreme mood swings
__________ from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers synthesis and secretion of milk after giving birth.
Prolactin
Uterine __________ occurs when the uterus descends through the pelvic floor and into the vaginal canal.
Prolapse
Vitamin K, a fat-soluble vitamin, promotes blood clotting by increasing the synthesis of __________ by the liver.
Prothrombin
The abdomen of a newborn typically appears __________ without appearing distended.
Protuberant
Physiologic Transitioning from Fetus to Newborn Status System: Respiratory Gas Exchange Circulation through Heart Hepatic portal circulation Thermoregulation
RESPIRATORY Fetus: - Fluid filled, high pressure system causes blood to be shunted from the lungs through the ductus arteriosus to the rest of the body Newborn: - Air filled, pressure system encourages blood flow through the lungs for gas exchange; increased oxygen content of blood in the lungs contributes to the closing of the ductus arteriosus GAS EXCHANGE Fetus: - Placenta Newborn: - Lungs CIRCULATION THROUGH HEART Fetus: - Pressures in the right atrium are greater than in the left, encouraging blood flow through the foramen ovale Newborn: - Pressures in the left atrium are greater than in the right, causing the foramen ovale to close HEPATIC PORTAL CIRCULATION Fetus: - Ductus venosus bypasses; maternal liver performs filtering functions Newborn: - Ductus venosus closes (becomes a ligament); hepatic portal circulation begins THERMOREGULATION Fetus: - Body temperature is maintained by maternal body temperature & the warmth of the intrauterine environment Newborn: - Body temperature is maintained through a flexed posture and brown fat
__________ is the process by which the infant's capabilities and behavioral characteristics elicit parental response.
Reciprocity
Rectocele occurs when the __________ sags and pushes against or into the posterior vaginal wall.
Rectum
The first axillary lymph node tested to determine the spread of breast cancer is called the __________ lymph node.
Sentinel
Nevus vasculosus is also called a __________ hemangioma.
Strawberry
If retrogressive changes do not occur as a result of retained placental fragments or infection, __________ results.
Subinvolution
The mother goes through 3 distinct phases of adjustment in the postpartum period: 1. Taking in 2. Taking hold 3. Letting go Explain each as if you were teaching the patient about this on discharge from the hospital.
Taking in (1-2 days after delivery) - Contemplation of her recent birth experience - Assumption of passive role and dependence on other for care - Verbalization about labor and birth - Sense of wonderment when looking at the neonate Taking hold (2-7 days after delivery) - Increased independence in self-care - Strong interest in caring for the neonate that's often accompanied by a lack of confidence about her ability to provide care Letting go (about 7 days after delivery) - Adaption to parenthood and definition of new role as parent and caregiver - Abandonment of fantasized image of neonate and acceptance of real image - Recognition of neonate as a separate entity - Assumption of responsibility and care for the neonate
What nutritional recommendations can a nurse provide to a client during the postpartum period?
The new mother might ignore her own needs for health and nutrition. She should be encouraged to take good care of herself and eat a healthy diet so that the nutrients lost during pregnancy can be replaced and she can return to a healthy weight. The nurse should provide nutritional recommendations, such as - Eating a wide variety of foods with high nutrient density - Using foods and recipes that require little or no preparation - Avoiding high-fat, fast foods and fad weight-reduction diets - Drinking plenty of fluids - Avoiding harmful substances such as alcohol, tobacco, and drugs - Avoiding excessive intake of fat, salt, sugar, and caffeine - Eating the recommended daily servings from each food group
Discuss ways a nurse can model behavior to facilitate parental role adaptation and attachment during the postpartum period.
The nurse should model behavior to family members as follows: - Holding the newborn close and speaking positively - Referring to the newborn by name in front of the parents - Speaking directly to the newborn in a calm voice - Encouraging both parents to pick up and hold the newborn - Monitoring newborn's response to parental stimulation - Pointing out positive physical features of the newborn
What suggestions can a nurse provide to the parents to minimize sibling rivalry during the postpartum period?
The nurse should suggest the following to the family to avoid sibling rivalry: - Expect and tolerate some regression - Discuss the new infant during relaxed family times - Teach safe handling of the newborn with a doll - Encourage older children to verbalize emotions about the newborn - Move the sibling from the crib to a youth bed months in advance of the birth of the newborn
What are the causes of postpartum stress?
The physical stress of pregnancy and birth, the required care-giving tasks associated with a newborn, meeting the needs of other family members, and fatigue can cause the postpartum period to be quite stressful for the mother.
Explain why breastfeeding is not a reliable method of contraception.
The timing of the first menses and ovulation after birth differs considerably in lactating and nonlactating women. In nonlactating women, menstruation resumes 7 to 9 weeks after giving birth; the first cycle is anovulatory. In lactating women, the return of menses depends on the frequency and duration of breastfeeding. It usually resumes anytime from 2 to 18 months after childbirth, and the first postpartum menses is usually heavier and frequently anovulatory. However, ovulation may occur before menstruation, so breastfeeding is not a reliable method of contraception.
The balance between heat loss and heat production is termed __________.
Thermoregulation
What is the proper way to check the position of a postpartum patient's fundus?
To palpate the uterine fundus, support the lower segment of the uterus with a hand placed just above the symphysis pubis (this steadies the uterus and prevents downward displacement) then gently palpate the fundus (top of the uterus) with your other hand to evaluate firmness and location
__________ ultrasound is used to distinguish fluid-filled ovarian cysts from a solid malignancy.
Transvaginal
A cyst palpated in the breast is usually mobile and tender.
True
A newborn experiencing heat loss can develop cold stress.
True
A slight temperature elevation is normal during the first 24 hours after delivery.
True
Cancer is the second leading cause of death for women in the United States.
True
Gardasil is the first vaccine developed to prevent cervical cancer.
True
Ovarian cancer during pregnancy is rare.
True
Oxygen is the most important factor in controlling closure of the ductus arteriosus.
True
Profuse diaphoresis is common during the early postpartum period.
True
Pulmonary embolism is a major cause of maternal mortality.
True
The majority of ovarian cysts are benign.
True
The most common type of breast cancer is invasive ductal carcinoma.
True
The postpartum woman commonly exhibits bradycardia.
True
The postpartum woman's bladder should be nonpalpable.
True
If required immediately after birth, a newborn's mouth is suctioned first, then the nose.
True Debris is suctioned first from the back of the mouth to avoid aspiration into the lungs when the nose is suctioned.
An Apgar score of 8 or better is a normal finding for a newborn.
True When a newborn has an Apgar score less than 8 at 5 minutes of age, a third score is performed at 10 minutes of age.
Acrocyanosis is normal and occurs intermittently in a newborn.
True Acrocyanosis occurs in the newborn in response to exposure to cold.
At birth, the average newborn weighs 7 lb, 8 oz.
True At birth, the average newborn weighs 7.5 lb (3,400 g), with normal birth weights ranging from 5 lb, 8 oz to 8 lb, 13 oz (2,500 to 4,000 g).
__________ is a useful adjunct to mammography that produces images of the breasts by sending sound waves through a conductive gel applies to the breasts.
Ultrasound
Weakened pelvic floor musculature also prevents complete closure of the __________, resulting in urine leakage during moments of physical stress.
Urethra
During pregnancy, stretching of the abdominal wall muscles occurs to accommodate the enlarging __________.
Uterus
Measure the newborn's head circumference at its __________ diameter.
Widest
When should we educate women to do a self breast exam?
Women should perform a self breast exam monthly preferably one week after their menses
