Exam 3 PP & NB

indications baby is eating enough

- hunger cues: mouthing hands, rooting, sucking, crying (late) - completed feedings: slowing of suckling, softened breast, sleeping - baby is satisfied, gaining weight, and there are 6-8 diaper changes a day

What is endometritis?

- infection of the endometrium - common postpartum infection - presents with purulent foul smelling lochia -inflammation of the inner lining of the uterus -Broad spectrum antibiotics are used to treat infection -Restore and promote fluid and electrolyte balance

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother?

indirect Coombs test Explanation: The indirect Coombs test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh-positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to check for immunization and autoimmune disorders.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature Explanation: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

Normal NB BP

50-75 mmHg systolic, 30-45 mmHg diastolic

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL Explanation: Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 mL after a vaginal birth and greater than 1,000 mL after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process.

Mom Temperature PP

slight elevation during the first 24 hours (because of dehydration and fluid loss during labor); normal afterward; temp above 100.4 at any time after the 24 hours may indicate infection and MUST be reported

Lochia rubra

· deep red mixture of mucous, tissue debris and blood that occurs for the first 3-4 days

Lochia Amount: Excessive

· one pad saturated in 15 min or pooling of blood under buttocks

formula fed NB stool

· yellow, yellow green, loose, pasty, or formed, unpleasant odor

breast fed NB stool

· yellow-gold, loose, stringy to pasty, sour-smelling

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply.

Provide oxygen supplementation. Ensure the newborn's warmth. Observe respiratory status frequently. Explanation: The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back.

small for gestational age (SGA)

- etiology: malnutrition, vascular complications - intrauterine growth restriction (IUGR) - determined by US - identify moms risk factors: smoking, previous pregnancies with SGA -Weight less than the 10th percentile on standard growth charts (usually >5.5 lb) - <28 weeks leading to overall growth restriction (never catch up in size) ->28 weeks intrauterine malnutrition (normal growth protentional with optimal postnatal nutrition)

A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective?

"We will turn the mobile on that's hanging on our baby's crib." Explanation: Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly or play calming music or white noise. Swaddling the newborn rather than placing the infant on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed?

"When I am sleeping or lying in bed, I should lie flat on my back." Explanation: With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions.

transient tachypnea of the newborn (TTN)

-C section babies -Typically resolves by 72 hours of age -Wheezing, wetness in lungs -Barrel-shaped chest -May have to lavage them -Resp rate >80 -If pulse is >160 notify HCP -Nursing action: · Provide oxygen · Ensuring warmth · Observing resp status frequently · Allowing time for pulmonary capillaries and the lymphatics to remove the remaining fluid (usually 24 hours) - caused by retained amniotic fluid in the lungs of C/S babies - s/s: delayed presentation, RR > 80, grunting - management: IV fluids, gavage feedings, NPO, and monitor VS

PP psychosis can be? Occurs?

-Onset can be abrupt -Occurs around 3 months PP; previous hx of mental illness

PP blues usually peaks at?

-Usually peaks at days 4 to 5 and resolves by day 10 -If GREATER THAN 10 days seek treatment!

PP nonpharmacologic for pain 1st 24 hrs

-heating pad/warm cloth afterbirth pains -ice packs for episiotomy pain (1st 24 hrs)

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider?

100.8°F (38.2°C) Explanation: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?

Administer aquamephyton. Explanation: Aquamephyton, or vitamin K, is used to promote blood clotting in the newborn and is priority to administer to the newborn. The hearing test, hepatitis B vaccine, and newborn screening should all be completed prior to discharge.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure Explanation: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

How often do you assess lochia?

Assess every 15 min 1st hour, every 30 min 2nd hour, every hour after the 2nd hour

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions. Explanation: Home visitation programs provide caregivers with opportunities to do return demonstrations of care, ask questions of a professional, and be reassured of their ability to care for their infant. The visiting nurses do not take over care of the infant or serve as an arbitrator for disagreements. All necessary procedures will be completed in the hospital prior to discharge.

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply.

Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support Explanation: Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.

Nevus vasculosus (strawberry mark)

Strawberry mark: raised, clearly delineated, dark-red, rough-surfaced birthmark commonly found in the head region.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

infant

after 28 days of life

Kernicterus

billirubin in CSF

salmon patch (stork bite)

common capillary vascular formation. most frequently on mid-forehead, eyelids, upper lip, and back

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

concentration of immature blood vessels Explanation: A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns. An allergic reaction would be more generalized and would not be salmon-colored.

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

during the first 24 hours after birth owing to dehydration from exertion Explanation: Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.

What does Mastitis look like?

engorged breasts, erythema, warm, flu-like symptoms, fever - inflammation/infection of the breasts - not emptying each breast with feedings - complain of flu like symptoms (fever) - become engorged, warm, and erythema - keep emptying breasts, pain management, and antibiotics

neonates

first 28 days of life

Mom pain PP

goal between 0 to 2 on pain scale

One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which method would the nurse identify as best to control infection?

handwashing Explanation: Educate parents about appropriate home measures that will prevent infections, such as practicing good handwashing, keeping the newborn well hydrated, avoiding bringing the infant into crowds, observing for early signs of infection, and keeping pediatrician appointments for routine visits

Mom BP PP

normal to lower

handwashing

important to reduce risk of infection to the baby

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

inability to concentrate loss of confidence decreased interest in life Explanation: The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

lethargy cyanosis jitteriness Explanation: The nurse should monitor the newborn for lethargy, cyanosis, and jitteriness. Low-pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintaining previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

erythema toxicum

newborn rash

Newborns that are fed early

pass stools sooner, which helps reduce bilirubin buildup

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony Explanation: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

newborn sensory abilities

vision, hearing, taste, smell

second period of reactivity in newborn

· 2 to 8 hours · Newborn awakens and shows and interest in stimuli

Lochia Amount: Scant

· 2-inch stain (10 ml)

Period of decreased responsiveness

· 30 to 120 minutes old · Period of sleep or decreased activity

Lochia Amount: Small

· 4-inch stain (10 to 25 ml)

Lochia Amount: Moderate

· 6-inch stain (25 to50 ml)

circumcision care

- instruct patient to change diaper every 4 hours and clean with warm water - do not immerse in tub until fully healed - notify HCP of any redness, discharge, swelling, or foul odor - instruct that a film of yellowish mucus can form and it is important to not wash it off - do not clean with pre moistened towelettes that contain alcohol - will heal completely within a couple of weeks

newborn weight loss

- loss of 5%-10% birth weight is normal - start regaining around 10-14 days

The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema. Explanation: This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?

Expose the newborn's bottom to air several times a day. Explanation: The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis Explanation: Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?

Report the finding to the pediatrician. Explanation: Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.

respiratory distress syndrome

Respiratory distress S/SX: · Nasal flaring · Grunting · Retracting · Tachypnea (>60 /min) · Cyanosis

endometritis s/s

· Fever (>100.4) · Lower abd pain or tenderness on one side or both sides · Foul smelling lochia · Anorexia · Nausea · Fatigue · Leukocytosis

Lochia Amount: Large

· >6-inch stain (50 to 80 ml) saturated within 1 hour after changing it

BUBBLE-PLEB: Uterus

· Fundus, firmness · If the uterus is more to the right and above the umbilicus = full bladder (ask mom to urinate) · Normally, the fundus progresses downward at a rate of 1 cm per day after childbirth (1cm below umbilicus on the first day pp) and should be nonpalpable by 10 to 14 days PP · We want the uterus to be firm · Fundus should be midline and should feel firm · If the fundus is not firm, gently massage the uterus using a circular motion until it becomes firm

Tx to reduce the pain of breasts engorgement

· Heat or cold applications · Cabbage leaf compression · Breast massage · Milk expression · Ultrasound · Breast pumping · Anti-inflammatory agents

PP blues s/s

· Mild depressive symptoms · Anxiety · Irritability · Mood swings · Tearfulness · Increased sensitivity · Fatigue

uterine atony

- uterus becomes boggy and does not contract - most common cause of postpartum hemorrhage - caused by bladder distension - gently massage the uterus to keep it contracting (can cause uterine inversion)

Proper breastfeeding position

-The football hold: the mother holds the infant back and shoulders in her palm and tucks the infant under her arm -The cross-cradling position: most commonly used. The mother holds the baby in the crook of her arm, with the infant facing the mother

caput

- edema of scalp tissue - crosses the suture line - ill defined, soft, non-fluctuant mass, pitting edema - onset within 24 hours after birth -Localized edema on the scalp that occurs from the pressure of the birth process. -It is commonly observed after prolonged labor -It appears as a poorly demarcated soft tissue swelling that crosses suture lines

Mongolian spots

areas of deep bluish-gray pigmentation most commonly on the sacral aspect of a newborn

BUBBLE-PLEB stands for?

Breasts Uterus Bladder Bowels Lochia Episiotomy Pain Legs Emotional Status Bonding

C- Section Baby lungs

Rails, moist crackles, wet sounding

BUBBLE PLEB: Lochia

· Amount, color, odor · Assess every 15 min 1st hour, every 30 min 2nd hour, every hour after the 2nd hour

Lochia

Lochia has a definite musky odor similar to menstrual flow without any large clots -Foul smelling lochia suggests an infection -Large clots suggest poor uterine involution

BUBBLE PLEB: Bladder

· Assess the bladder for distention and adequate emptying after efforts to void · Note the location and condition of the fundus; a full bladder tends to displace the uterus up and to the right

BUBBLE-PLEB: Bowel

· Bowel sounds, distention · Normal patterns of elimination occur with a week after birth · Stool softeners and laxatives are gives to reduce strain

PP hemorrhage causes?

· Uterine atony (MOST COMMON) · Lacerations of the genital tract · Episiotomy · Retained placental fragments · Uterine inversion · Coagulation disorders · Hematomas of the vulva, vagina, or sub peritoneal areas

thromboembolic disease

- inflammation of blood vessel lining - major causes: venous stasis and hypercoagulation - most common types: superficial thrombosis and DVT - virchow's triad: venous stasis, injury to innermost layer of blood vessels, and hypercoagulation

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness Explanation: Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more

nursing assessment and management of infection

- REEDA: redness, edema, ecchymosis, discharge, approximation of edges- prevention: aseptic technique, hand washing, perineal hygiene, screening of visitors- administration of antibiotics and wound care

complications of SGA

- asphyxia - aspiration - hypothermia - hypoglycemia - polycythemia

Good bowel hygiene PP

- bowel movement after birth or with stitches may hurt - take in more fiber, increase fluid intake, use stool softeners if needed, and early ambulation

normal VS postpartum

- bradycardia (40-60 bpm) - low grade temp for first 24 hours - diuresis - after birth pain: happens after multiple pregnancies; intense uterine contractions after delivery

prevention of DVTs

- encourage activity and ambulation - flexion of the feet with prolonged sitting to promote venous return - use of SCDs - extremity elevation - stop/avoid cigarette smoking - ted hose (remove daily for inspection) - post-op breathing exercises - use of ASA or anti-coags - avoid pillows under the knee or crossing legs for prolonged periods - frequent position changes - avoid trauma to the legs to prevent injury to the veins - adequate fluid intake - avoid use of OCP

PP infection

- fever 100ºF after the first 24 hours - caused by organisms of the normal vaginal flora (aerobic and anaerobic) - infections include metritis, mastitis, wound, and UTI

When to call HCP with NB

-Temp above 38 C (100.4 F) axillary or below 36.6 C (97.8 F) axillary -Continual rise in temp -Refusal of two feedings in a row -Cyanosis with or without feeding -No wet diapers for 18 to 24 hours or fewer than six to eight wet per day after 4 days of age -Two consecutive green watery black stools or increased frequency of stools

PP hemorrhage can be?

-Potentially life-threatening complication of both vaginal and c-section births -The injection of a uterotonic drug immediately after birth is an important intervention used to prevent PPH

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness. Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

Vitamin K

-Promotes blood clotting by increasing the synthesis of prothrombin by the liver -A deficiency of this vitamin delays clotting and might lead to hemorrhage. -Provides the newborn with vitamin K during the first week of birth until the newborn can manufacture it -Given into the outer middle third of the vastus lateralis muscle

Erythromycin ointment

-Provides bactericidal and bacteriostatic actions to prevent Neisseria gonorrhea -Prevents ophthalmia neonatorum (severe form of conjunctivitis that is potentially blinding condition in newborns) given prophylactically for eye infections from bacteria in the birth canal

diastasis recti postpartum

-Separation of the rectus muscles -Can be resolved by exercise -If rectus muscle tone is not regained through exercise, support may not be adequate for future pregnancies

NB stools

-Stools start at meconium (1-3 days), then transitional stools (day 4), then milk stool

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"The opening of his urethra in located on the under surface of the tip of the penis." Explanation: The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off." Explanation: In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

fluid requirements for newborns

100 (first 24)-140 ml (after 24)/kg/24 hours

Normal NB HR

110-160 bpm

Mom respirations PP

16 to 24 breaths per min; clear to auscultation

The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage?

24 hours to 12 weeks after birth Explanation: Mothers who give birth to twins are instructed on postpartum hemorrhage at the same time as a mother with a single newborn. Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth.

Normal NB RR

30-60 breaths per minute; will increase with crying

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?

Ambulate the client as soon as her vital signs are stable. Explanation: The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask to see the woman' hospital identification badge. Explanation: The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema. Explanation: Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus. Explanation: The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her. Explanation: Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently. Explanation: The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein pearls. Explanation: Epstein pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Oral candidiasis (thrush) is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative Explanation: Evaporative heat loss occurs with the evaporation of fluid from the infant.

nevus flammeus

Permanent purple birthmark; also called port-wine stain.

Lochia serosa

Pinkish/brown, serosanguineous. Lasts day 4-10 postpartum

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops. Explanation: The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptive pills (OCPs).

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?

Risk for fatigue related to chronic bleeding due to subinvolution Explanation: Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

Lochia alba

Whitish/yellowish discharge - lasts 10-14 days, may last 3-6 weeks and remain normal.

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

Within one hour Explanation: Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia.

A 25-year-old nulliparous client presents in active labor. She has had no prenatal care, and her coagulation status is determined. Which result would the nurse identify as placing the client at risk for postpartum hemorrhage?

activated partial thromboplastin time 60 seconds Explanation: Activated partial thromboplastin time of 60 seconds is increased and suggestive of a coagulopathy. The platelet count, prothrombin time, and INR are within normal parameters.

Apgar scale

appearance, pulse, grimace, activity, respiration

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism?

calf swelling Explanation: The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage. Sudden change in the mental status, difficulty in breathing, and sudden chest pain are manifestations of pulmonary embolism, beyond the stage of prevention.

vernix caseosa

cheesy substance covering the skin of the fetus

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage Explanation: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.

Milia

small raised white spots on nose, chin, and forehead

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg Explanation: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?

"I only eat a low-fiber diet." Explanation: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

The parents of a 2-day-old newborn are getting ready to go home with their baby. The mother is breastfeeding the newborn. In preparation for discharge, the nurse obtains the newborn's weight. The newborn weighs 7 lb (3180 g) this morning. The parents voice concern, saying, "Our newborn lost weight since being born. Our newborn was 7 lb 8 oz (3404 g) and now our newborn is less. What is going on?" Which response by the nurse would be most appropriate?

"I understand your concern. It is normal for this to happen but your newborn will gain it back quickly." Explanation: Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life. The weight loss is a normal finding. There is no need to talk to the health care provider, increase the number of breastfeeding sessions, or switch to formula.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." Explanation: After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?

"You need to avoid medications which contain acetylsalicylic acid." Explanation: The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. Explanation: A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?

Assess the newborn for signs of respiratory distress. Explanation: Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed Explanation: When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum Explanation: Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

applying ice Explanation: Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

While caring for a neonate of a diabetic mother, the nurse should monitor the neonate for which complication?

macrosomia Explanation: Neonates of diabetic mothers are at increased risk for macrosomia (excessive fetal growth) due to the increased supply of maternal glucose combined with an increase in fetal insulin. Along with macrosomia, neonates of diabetic mothers are at risk for respiratory distress syndrome, hypoglycemia, hypocalcemia, hyperbilirubinemia, and congenital anomalies. They aren't at greater risk for atelectasis or pneumothorax. Microcephaly is usually the result of cytomegalovirus or rubella virus infection.

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Explanation: Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply.

vital signs of mother pain level head-to-toe assessment Explanation: Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs Explanation: While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?" Explanation: The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching?

"Some women just can't breastfeed. Maybe I'm one of these women."

cold stress

- excessive heat loss leads to hyperthermia which causes utilization of compensatory mechanisms to maintain body heat - will not shiver: jitteriness, irritability - s/s: temp < 97.6ºF, lethargy, jitteriness, tachypnea, weak tone - place baby in warmer, dry thoroughly, remove any wet items, keep baby away from windows or vents

Mastitis

-Painful infection of the breast tissue -Possible causes are a blocked milk duct or bacteria entering the breast -Typically occurs within the first 3 months of breast feeing -Risk factors: · Statis of milk d/t infrequent, inconsistent breastfeeding · Previous episodes of mastitis · Nipple trauma -S/SX: · Flu-like symptoms, malaise, fever, chills · Tender, hot, red, painful areas on one breast · Inflammation of breast area · Breast tenderness · Cracking of skin around nipple or areola · Breast distention with milk -Antibiotics are required -Mild pain relivers can help with discomfort

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly Explanation: The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercises. Explanation: Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly. Explanation: Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus. Explanation: The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air. Explanation: Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent fussiness by burping them frequently throughout the feeding. Therefore, the best suggestion would be to have the parent burp the newborn. The newborn may or may not be full; the newborn may still be hungry but excess air in the stomach is making the newborn fussy. Feeding is a time for closeness. Propping a bottle interferes with bonding and increases the risk of choking and other problems. Stopping the feeding and then restarting it would do nothing to help alleviate the swallowed air and may contribute to more air being swallowed.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?

Escherichia coli Explanation: E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother?

Feeding the infant more formula whenever she begins to fuss Explanation: Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B Explanation: Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit. Vitamin K is given soon after birth to reduce the risk of bleeding.

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination. Explanation: An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm. The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

lack of subcutaneous fat Explanation: Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying.

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as:

moderate. Explanation: Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis Explanation: The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment?

rooting Explanation: The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear.

PP hemorrhage blood loss means?

· >500 ml following a vaginal birth · >1000 ml following c section

Mom PP assessments are typically performed

· During the first hour: every 15 min · During the second hour: every 30 min · During the first 24 hours: every 4 hours

PP psychosis s/s

· Mood lability · Delusional beliefs · Hallucinations · Disorganized thinking · Anger -Early symptoms mimic depression, sleep disturbance, fatigue -DO NOT leave mother alone with infant

BUBBLE-PLEB: Breast

· Size, contour, engorgement · Engorged breasts are hard, tender, and taut

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." Explanation: A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding.

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents?

"Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

A postpartum client has decided to bottle feed her newborn. After teaching the woman about it, the nurse determines that the teaching was successful based on which client statement(s)? Select all that apply.

"I will be sure not to use the microwave to warm the formula." "I will make sure the nipple and neck of the bottle are filled with formula during a feeding." "I will get my newborn to suck by touching the nipple to the lips." Explanation: Teaching about bottle feeding should include the following: mixing powdered formula with room temperature water to allow better mixing and quicker dissolution of lumps; storing any formula prepared in advance in the refrigerator to keep bacteria from growing but discarding any formula not taken during a feeding; making sure that the nipple and neck of the bottle are always filled with formula to prevent the newborn from taking in too much air; and stimulating the sucking reflex by placing the nipple to the newborn's lips.

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels to return to their normal pattern." Explanation: Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." Explanation: The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

Cord care for newborn

- do not immerse in tub until cord has fallen off - sponge baths are given until it falls off - clamp should be removed before discharge - keep cord dry and keep the top of the diaper folded underneath it - report to HCP: moist and red cord, foul odor, or purulent drainage

sibling adaptation

- give gifts from the newborn to the sibling - let the sibling be involved in the care of the newborn - spend adequate time with the siblings to prevent jealousy

successful bottle feeding

- hold infant at a 45 degree angle - make sure there is no air in the nipple - do not microwave formula - need 8-12 feedings/24 hours (every 2-3 hours)

pathologic jaundice

- occurs in the first 24 hours of life - maternal antibodies cross the placenta and attach to fetal RBCs and destroys them - evaluate all Rh negative and O positive women: draw cord blood to check baby's blood type can lead to kernicterus

how to test for hip dysplasia

- to assess: lay infant on abdomen and straighten legs - look for gluteal and thigh creases - should be equal

Signs of sepsis in newborn

-Acquired bacterial or viral organisms from infected amniotic fluid, maternal infection, or direct contact while passing through the birth canal -Symptoms are unspecific? -Assess the newborn for common nonspecific signs of infection · Temperature instability · Hypotension · Tachycardia · Pallor · Hypotonia · Cyanosis

Moro reflex (startle reflex)

-Also called the embrace reflex, occurs when the neonate is startled -Place the newborn on his or her back -Support the upper body weight of the supine newborn by the arms, using a lifting motion, without lifting the newborn off the surface -then release the arms suddenly - baby is startled at loud sounds or jumps when being picked up

CARDIOVASCULAR SYSTEM ADAPTATIONS: PP

-Blood volume drops rapidly -Cardiac output increases during intrapartum and remains elevated for a few days post-partum -Mild bradycardia -Coagulation factors are elevated (increased risk for thromboembolic problems) -Wbc production is increased (around 20,000 = be concerned) -Increased wbc with fever = not normal

CALCULATING CALORIE REQUIREMENTS:

-During the first 3 months, and infant needs 110 to 120 calories/kg/day -Fluid requirements: 100-150 ml/kg/day -To gain weight the newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age -Not unusual for a baby to lose 5 to 10% of initial birth weight, will gain back a/b 10 days after birth

Danger Signs Postpartum

-Fever >100.4 f -Foul smelling lochia or unexpected change in color or amount -Large blood clots, or bleeding that saturates a perineal pad in an hour -Severe headaches or blurred vision -Visual changes, such as blurred vision or spots -Calf pain dorsiflexed -Swelling, redness, discharge at episiotomy, epidural, or abd sites -Dysuria, retention -SOB -Depression

large for gestational age (SGA)

-Large for gestational age -Weight more than the 90th percentile on standard growth charts (usually >9 lb) -Typically, the mothers usually had DM or glucose intolerance -Postdated gestation -Maternal obesity -Characteristics: · Large body, plump, full faced · Proportional increase in body size · Poor motor skills · Difficulty regulating behavioral states

Cephalohematoma

-Localized subperiosteal collection of blood of the skull which is always confined by one cranial bone. -The swelling does not cross suture lines and is firmer to the touch than an edematous area -This condition is due to pressure on the head and disruption of the vessels during birth. - It occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum extraction -Large cephalhematomas can lead to increased bilirubin levels and subsequent jaundice

PP hemorrhage meds

-Methergine: · Stimulates the uterus to prevent and treat PPH due to atony or subinvolution · Contraindications: hypertension -Hemabate: · Stimulates uterine contractions to treat PPH due to uterine atony when not controlled by other methods · Contraindications: active CAD, asthma, renal/hepatic dx

Normal vs. Abnormal breathing in the NB

-The newborn respiratory rate ranges from 30 to 60 breaths per min -After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). -The newborn's respiratory rate varies according to their activity, the more active the newborn, the higher the respiratory rate on average -Respirations should not be labored, and chest movements should be symmetric

Skin Assessment findings in a NB

-Vernix caseosa: cheesy like substance in the creases, don't rub it off -Stork bites or salmon patches: marks on the back of the neck where, as myth goes, a stork may have picked up the baby -Milia: multiple pearly white or pale yellow unopened sebaceous glands frequently found on the newborns nose (NORMAL) -Mongolian spots: benign blue or purple spots found on fark skinned babies -Erythema toxicum: newborn rash -Nevus flammeus: port wine stain, appears on newborns face or other body areas -Nevus vasculosus: strawberry mark, raised, dark, red and sharply demarcated

Rhogam is given when?

-administer within 72 hours within giving birth in the mother is RH- and the baby is RH+ to prevent issues with their next pregnancy Administering RhoGAM prevents initial isoimmunization in RH- mothers by destroying fetal erythrocytes in the maternal system before maternal antibodies can develop and maternal memory cells become sensitized

NB hypoglycemia

-observed in diabetic mothers -Make sure temp is w/in normal range, then check BS - Plasma glucose concentration less than 45 mg/dl in the first 72 hours of life -DO not want it lower than 40 -Most newborns experience transient hypoglycemia and are asymptomatic -The symptoms, when present: · Jitteriness · Lethargy · Cyanosis · Apnea · Seizures · High-pitched, weak cry · Hypothermia -Rapid acting glucose source: · Dextrose gel · Breastfeeding · Formula feeding

Mom pulse PP

40 to 60 bpm; pleural bradycardia (because of psychological changes) Any pulse rate higher than 100 warrants further investigation

How do you know you know your baby is receiving adequate/proper nutrition?

6-8 Wet diapers a day

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10. Explanation: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

Normal NB Temperature

97.7-99.5

jaundice is

>5 mg/dl

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?

A female in her mid-20s who appears pregnant Explanation: Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant. Men are not typically abductors nor are honor students.

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?

Breastfeed the infant every 2 to 4 hours on demand. Explanation: Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is 0.66 oz to 1 oz (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra. Explanation: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Explanation: Vitamin K is given IM shortly after birth and, if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was given. Vitamin K is given IM, not oral. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered but not documented.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose. Explanation: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant. Explanation: "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A positive Homans sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for redness and warmth/ In addition, assess to see if she has increased pain when she ambulates or bears weight.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on mother. Explanation: Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.

A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client?

Encourage an oral intake of 2 to 3 liters per day. Explanation: Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 ml/hr. The other three actions are important but not the highest priority for this client.

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection. Explanation: A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.

The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn. Explanation: The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

Infection Explanation: Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn. Explanation: This rash is most likely is erythema toxicum, also known as newborn rash.

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

Mastitis Explanation: Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and painful to palpation. The scenario described is not indicative of a plugged milk duct or engorgement. Yeast is not recognized to cause mastitis.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breastfeeding. Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold (not warm) moist heat to the breast. Gently massaging the affected area of the breast also helps.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond?

Pierced nipple Explanation: Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping. Explanation: It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

Engorgement of breasts

Postnatal physiologic painful condition in which distention and swelling of the breasts tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation -Peaks in 3 to 5 days PP and usually subsides within the following 24 to 36 hours

The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K?

Provides blood clotting factors Explanation: Vitamin K is necessary in the formation of certain clotting factors. The newborn male and female are both lacking in vitamin K, and the only method for the infant to receive it in the early hours after birth is to administer the vitamin IM. Vitamin K is manufactured by normal flora in the gut. Since the newborn has not yet eaten, there is no normal flora in the gut, so the infant cannot manufacture vitamin K. Vitamin K does not speed up drying of the umbilical stump or stimulate population of normal gut flora. It can help reduce possible bleeding from circumcision; however, that is not the only complication that can occur from a circumcision, nor is a circumcision the only reason an infant might bleed.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families. Explanation: To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

She should continue to breastfeed; mastitis will not infect the neonate. Explanation: The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

The bladder is distended. Explanation: If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate. Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes. Explanation: Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?

The urinary output is normal. Explanation: Expected urinary output for a postpartum woman is at least 150 mL with each void on an hourly basis. Therefore 150 to 200 mL is a normal volume for each void.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours. Explanation: The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

Which postpartum client will the nurse assess first?

a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated Explanation: A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. If blood pressure is 15 to 20 mm Hg lower after raising the head of the bed upright compared with the supine reading, the woman might be susceptible to dizziness and fainting when she ambulates. Developmentally, 18-year-old teenagers may stay up late and sleep late as a normal sleep cycle. The young 22-year-old packing for discharge is not the priority. A client who had a cesarean birth with minimal blood loss should be allowed to sleep after receiving pain medication and is not the priority.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar Explanation: Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl).

The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?

deep venous thrombosis Explanation: Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity.

A postpartum woman has a history of von Willebrand disease (vWD). The client is being prepared for discharge, and a referral for health care follow-up is made to assess for potential postpartum hemorrhage. The nurse understands that this client is at greatest risk for hemorrhage during which time during the postpartum period?

first week Explanation: During pregnancy, the von Willebrand factor level increases in most women; thus, labor and birth usually proceed normally. However, all women should be monitored for excessive bleeding, particularly during the first week postpartum.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign. Explanation: Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?

hearing Explanation: Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long-term obesity Explanation: Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus Explanation: After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. Which nursing assessment(s) should the nurse prioritize to begin each nursing shift? Select all that apply.

pain platelet count clotting profiles evidence of bleeding Explanation: Thrombophlebitis interrupts blood flow causing pain. A pain assessment is needed every shift. The nurse should also monitor platelet counts and clotting profiles and assess bleeding in the client prescribed heparin therapy, an anticoagulant. Monitoring fluid status would be important for any client. This assessment would not specifically reveal complications or concerns related to the client receiving heparin therapy.

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

postpartum depression. Explanation: Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of:

postpartum depression. Explanation: Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism. Explanation: These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities Explanation: Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the pre-pregnancy state.

A nurse is reviewing the labor and birth record of a postpartum woman. The nurse determines the need for frequent monitoring for infection based on which factors in the woman's history? Select all that apply.

use of regional anesthesia for birth use of fetal scalp electrode for internal fetal monitoring forceps-assisted vaginal birth history of gestational diabetes Explanation: Factors that increase a woman's risk for postpartum infection include: prolonged rupture of membranes (greater than 18 to 24 hours); regional anesthesia that decreases the perception of the need to void; insertion of fetal scalp electrode or intrauterine pressure catheters for internal fetal monitoring during labor (provides entry into uterine cavity); instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk of trauma to genitalia); and gestational diabetes (decreases body's healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth).

first period of reactivity in newborn

· Birth to 30 minuets to 2 hours after birth · Newborn is alert, moving, may appear hungry

Inspect umbilicus for:

· Bleeding · Infection · Inflammation · Redness · Swelling · Purulent drainage or bleeding · Erythema around the umbilicus -Nurses should instruct mothers to wash their hands before expressing their milk, apply several drops of breast milk to the umbilical stump, and allow it to dry

BUBBLE PLEB: Episiotomy/incision

· Observe stitches · The perineal tissue surrounding episiotomy is typically edematous and slightly bruised · Assess at least every 8 hours for signs of infection · A white line running the length of the episiotomy is a sign of infection · Ice can be applied to relieve discomfort and reduce edema; sitz baths also can promote comfort and perineal healing

PP Psychosis Tx

· Psychotropic drug's · Psychotherapy Support groups

Keys to remember with PP hemorrhage

· Recognize s/s of hypovolemic shock · Vital signs are not a reliable indicator of extent blood loss · 1800-2100 ml lost before clinical sings present · Most pp hemorrhage deaths are d/t ineffective management of slow, steady blood loss · Cannot delegate assessments, admit, or discharge teaching

PP Depression S/S

· Restlessness · Worthlessness · Guilt · Loss of libido · Feelings of being overwhelmed · Lack of concern for herself or baby · Lack of interest in her baby · Worry about hurting the baby · Withdraw from friends/family

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns?

"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Explanation: Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination.

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." Explanation: Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early.

Phototherapy

- lowers bilirubin thorough photo-oxidation - rotate the baby's position to cover all surfaces - monitor I&Os and VS - diaper changes frequently: excreting bilirubin through stool and urine - keep eyes covered and keep hydrated -Exposing newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted through feces and urine -Eyes are covered, newborn is only in diaper -When caring for newborns receiving phototherapy: · Closely monitor body temp and fluid electrolyte levels · Document frequency, character, and consistency of stools · Turn frequently to increase the infants skin exposure · Observe skin integrity · Provide eye protection to prevent corneal injury

Physiologic Jaundice of the Newborn

- normal finding - occurs after the first 24 hours of life - combination factors: increased destruction and decreased excretion of bilirubin - bilirubin levels peak on days 3-5 - good feedings are essential: more they intake the more they excrete bilirubin · 3rd to 4th day of life · Occurs with cephalohematoma · Imbalance between the production and elimination of bilirubin · Monitor hydration status, stools, skin color (how the baby gets rid of the bilirubin) · You need to know the age of the baby (helps determine)

PP discharge teaching

- pain and discomfort should decrease as time goes on - stay up to date on immunizations: Tdap, rubella (MMR - do not get pregnant until after 1 month), flu - nutrition: increase fluid and fiber intake; take prenatal vitamins - HCP tells them when they can resume activity and exercise - breastfeeding is not a contraceptive; sex can resume when they feel like it - kegel exercises - lactation - follow up: first appt for both mom and baby will be made before they leave the hospital

PP discharge teaching for Mom & baby

- report to HCP: unexplained fever, drainage from wounds, weakness - schedule visits for both mom and baby before leaving the hospital -make sure they have phone numbers to the unit they were on and the lactation consultant if she is breastfeeding

involution of the uterus

- return of the uterus and fundus to its pre-pregnancy state - descends from the level of the umbilicus at a rate of 1 fingerbreadth/day - no longer palpable by approximately day 10 PP - can take up to 6 weeks to return to normal - fundus should be midline below the umbilicus (displaced to the right = empty bladder)

Apgar scoring

-Skin color: · Zero points: cyanotic or pale · One point: appropriate body color; blue extremities · Two points: completely appropriate color (pink on both trunk and extremities) -Pulse: · Zero points: absent · One point: slow (<100 bpm) · Two points: >100 -Reflex irritability: · Zero points: no response · One point: grimace or from when irritated · Two points: sneeze, cough, or vigorous cry -Muscle tone: · Zero points: limp, flaccid · One point: some flexion, limited resistance to extension · Two points: tight flexion, good resistance to extension with quick return to flexed position after extension -Respiratory: · Zero points: apneic · One point: slow, irregular, shallow · Two points: regular respirations (30-60), strong, good cry

Conduction heat transfer

-Transfer of heat from object to object when the two objects are in direct contact with each other -Refers to heat fluctuation between the newborn's body surface when in contact with other surfaces such as: · Cold mattress · Scale · Circumcision restraining board -Heat loss by conduction can also occur when touching a newborn with cold hands or when the newborn has direct contact with a colder object -Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps prevent heat loss through conduction -Also placing newborn skin to skin with mother helps prevent heat loss

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the full course of antibiotic prescribed, even if you begins to feel better. Explanation: Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply.

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow. Explanation: An infection of the breast during lactation is termed mastitis. Mastitis can interfere with lactation, and sometimes an infant will refuse to nurse on the affected side. The women's medical provider must be notified to initiate antibiotic treatment. Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis; there is no reason to provide alternative feeding methods or to wean because of maternal mastitis.

BUBBLE PLEB: Bonding

· The length of time necessary for bonding depends on the health of the infant and mother as well as the circumstances surrounding the labor and birth

PP depression lasts longer than?

PP blues and are more severe and require treatment!! -If untreated it could lead to poor bonding, alienation from loved ones, daily dysfunctions, and violent thoughts/actions

The 5 T's of PP hemorrhage (helpful way to remember the causes of PP hemorrhage)

· Tone: uterine atony, distended bladder · Tissue: retained placenta and clots · Trauma: vaginal, cervical, or uterine injury · Thrombin: coagulopathy (preexisting or acquired) · Traction: uterine inversion

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?

bringing the newborn into the room Explanation: Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

BUBBLE PLEB: Lower/Upper extremities

· Women at risk for PE should wear antiembolism or graduated compression stockings

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately?

oral temperature 100.8° F (38.2° C) Explanation: A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client?

oxytocin agent Explanation: The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.