NRS 240 Exam 2 Physiologic and Assessments pt. 3

Positive sign may indicate

the presence of a thrombus.

Nursing Interventions

warm blanket, warm drink, reassurance

•Why are postpartum women at increased risk for thromboembolism?

1. Mothers are in a hypercoagulative state. 2. PP - elevated plasma fibrinogen levels. 3. PP - Deep vein diameter and vessel damage and immobility.

When to Call a HCP (Incisions)

•Temperature > 100.4 •Foul smelling vaginal or incisional blood or discharge •Increased redness or pus from incision/episiotomy/laceration •Incision that is not healing

First Cycle of Menstruation and Ovulation are:

•Typically, anovulatory •Heavier than usual

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. A.Pain B.Warmth C.Discharge D.Ecchymosis E.Redness

A, B, and E.

Mother Immunizations: Influenza

Administer immediately PP if: not immunized & delivered during current flu season

Mother Immunizations: RhoGAM

•Indication: Rh- mother, Rh+ infant •Administer within 72 hours PP •Workup needed to determine dose: usually 300 mcg •IV push or IM •Protects again erythroblastosis fetalis (hemolytic disease of the newborn)

Perineum and Rectum Assessments

•Laceration •Episiotomy •Hemorrhoids

Promoting Comfort (perineum and rectum)

Dermaplast, ice, tucks, repositioning, stool softeners, laxatives, high fiber diet, and hydration.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? A.Fundus 1cm above the umbilicus, lochia rosa. B.Fundus 2cm above the umbilicus, lochia alba. C.Fundus 2cm below the umbilicus, lochia rubra D.Fundus 3cm below the umbilicus, lochia serosa.

Fundus 3cm below the umbilicus, lochia serosa.

Who is at increased risk for lower limb issues?

Hypercoagulability (factor V, DVT, PE) Severe anemia Obesity Traumatic delivery C/S Mag recovery

The nurse informs a postpartum woman that which of the following is the reason ibuprofen is especially effective for afterbirth pains? A.Ibuprofen is taken every two hours. B.Ibuprofen has an antiinflammatory effect. C.Ibuprofen is given via the parenteral route. D.Ibuprofen can be administered in high doses.

Ibuprofen has an antiinflammatory effect.

A client, G1P1, postpartum day 1, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2cm above the umbilicus. Which of the following actions should the nurse take first? A.Notify the woman's primary health care provider. B.Massage the uterus. C.Escort the woman to the bathroom to urinate. D.Check the quantity of lochia on the peripad.

Massage the uterus.

A G2 P2, who is postpartum 6 hours after vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? A.Do nothing. This is a normal finding. B.Massage the woman's fundus. C.Take the woman to the bathroom to void. D.Notify the woman's primary health care provider.

Notify the woman's primary health care provider.

Which of the following is the priority nursing action during the immediate postpartum period? A.Palpate the fundus B.Check pain level C.Perform pericare D.Assess breasts

Palpate the fundus

Believed Benefits of an Episiotomy

Prevention of tearing, ease of repair, reduced time/stress of 2nd stage of labor, decreased fetal head compression, easier operative vaginal delivery

Assessment for Perineum and Rectal Healing

REEDDA

REEDDA

Redness Edema Ecchimosis Discharge Drainage Approximation

Lactating effects on Menstruation and Ovulation:

•Mean ovulation time is 6 months PP •Menstruation returns as early as 12 weeks PP •may be delayed up to 3 years PP •Breastfeeding 1 month or < - return of menstruation similar to non-lactating women

Non-Lactating effects on Menstruation and Ovulation:

•Ovulation occurs as early as 27 days PP •Average 7-9 weeks PP •Menstruation resumes 12 weeks PP

When to call a HCP (Legs):

•Red or swollen leg •Painful and •Warm to the touch

Lower Extremity Assessment

•Redness, tenderness, increased temperature •Homans sign •Edema - unilateral vs. bilateral •Circumference •DTRs

Which laboratory finding would the nurse note as normal for a new mother following birth? A.An increase in hematocrit B.A drop in white blood cell count C.A decrease in coagulation factors D.Trace to 1+ proteinuria

Trace to 1+ proteinuria

hemorrhoid assessment

assess the size, number, and pain scale.

Postpartum chills

normal cold and shaking within hours of delivery related to vascular instability. •May occur immediately after birth •Benign finding if afebrile

Second Degree Laceration

extends through muscles of perineal body

Third Degree Laceration

extends through the anal sphincter muscle

First Degree Laceration

extends through the skin and structures superficial to muscles

Mother Immunizations: TDAP

given early, maximizes the maternal antibody response and passive antibody transfer to the fetus •A woman who did not receive the Tdap vaccine during her most recent pregnancy, but received it previously as an adolescent, adult, or during a prior pregnancy should not receive Tdap postpartum.

Cesarean Section Incision Assessment

i. Type & closure ii. Healing - REEDA iii. Surrounding skin iv. Pain

Fourth Degree Laceration

involves anterior rectal wall

Mother Immunizations: MMR

•Administered if rubella non-immune or equivocal •Avoid pregnancy for 4 weeks after administration •Administering with RhoGAM may interfere with desired immune response •SubQ

Incision Care

•Clean •Dry •Allow steri strips to fall off spontaneously •Staples usually removed day of d/c •Provena usually removed 1-2 weeks PP (outpatient)