Postpartum at Risk, Postpartum, 312 Exam 4

Vaginal infection—Group Beta Streptococci (GBS)

Considered normal flora in non-pregnant woman A concern in pregnancy Increased risk for preterm labor & transmission to newborn Screening in pregnancy 36-37 weeks Treat MOM with antibiotics during labor to prevent transmission to newborn during vaginal delivery

rectocele

Herniation of anterior rectal wall through relaxed vaginal fascia Appears as a large bulge that may be seen through relaxed vaginal introitus

Viral Infections

Herpes Virus Human Papilloma Virus (HPV) Hepatitis B Human Immunodeficiency Virus (HIV) Heb B & HIV are reportable communicable disease No curative treatments available treat only symptoms

Vaginal Infection--Bacterial Vaginosis

Not always sexually transmitted Most common type of vaginitis **Associated with preterm labor & birth* Symptoms: Thin grayish-white discharge Woman complains of a *fishy odor*

POSTPARTUM DIURESIS

Profuse diaphoresis, usually @ night for first 2-3 days after birth Caused by↓ estrogen levels Improved venous circulation of lower extremities Increased __*urinary output*_ Birth trauma to urethra Effects of conductive anesthesia

S/S of Subinvolution

Prolonged lochial discharge Uterus does not decrease in size as expected As noted by palpation Irregular or excessive bleeding Possibly hemorrhage

cystocele

Protrusion of bladder downward into vaginal wall Due to weakened supporting structures of bladder

PP Expected Blood Loss

Vaginal delivery _300-400__ml Cesarean Delivery _600-800_ml

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?

hemorrhage

Common Complications: IDM

Congenital Anomaly/ Cardiomyopathies Macrosomia Birth Trauma Perinatal Asphyxia/ RDS Hypoglycemia Polyhydramnios Polycythemia Hyperbilirubinemia

Exposure to Tobacco

Frequent cause of low birth weight infants Maternal cigarette smoking is implicated in 21-39% of LBW infants Second hand smoke: also leads to low birth weight infants Nicotine will be found in breast milk for two hours after mom has smoked

causes of uterine inversion

Fundal implantation of placenta Vigorous fundal pressure Excessive traction applied to cord Uterine Atony Adherent Placental tissue

Preterm Infant

Infant born before completion of 37th week of gestation Regardless of birth weight Organ systems are immature Responsible for 2/3 of all infant deaths Preterm babies have not had trouble adjusting in utero, they are just delivered early

Clinical/Nursing Management: respiratory distress

Maintenance of _warmth __ Oxygen prn Via ET tube/ventilator, mask, incubator, NC, blow-by Warmed & humidified Carefully monitor O2 concentration & delivery Too much O2 can lead to retinopathy of prematurity (ROP) Administration of synthetic surfactant ABG's & O2 sats O2 sat 88- 93% & not >95%

Diagnosis & Clinical Management

Maternal Antibodies are present after 32nd week of gestation If newborn is tested right away, positive antibody result could be mom's antibodies—not infants

Other signs/symptoms that might indicate sepsis

Maternal fever during labor Foul smelling amniotic fluid Prolonged ROM Prolonged labor

Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next?

Provide the client with a warm blanket.

Nursing Care: Phototherapy

infant is unclothed Eyes must be protected by an opaque mask Eyes should be closed under mask Mask should not occlude nares Infants' temp should be closely monitored Feedings should be adequate to prevent dehydration Amount of urine output & number of stools should be monitored Baby may go home with phototherapy

Late Onset Illness: strep b group

instead of Respiratory distress, meningitis tends to be more common Symptoms start about 1 week to 3 months after birth 50% have long term neurological consequences

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra

Neonatal Infections: Sepsis

Presence of microorganisms or toxins in blood Major cause of neonatal morbidity/ mortality Sepsis May be Acquired: In-utero During birth During resuscitation Nosocomial

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further?

perineal lacerations

Neonatal Infections

Sepsis Torch Bacterial

PDA: Clinical Manifestations

Systolic murmur Bounding peripheral pulses Tachycardia Crackles/Pulmonary Edema Hepatomegaly Enlarged heart

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason?

to prevent Rh-positive sensitization with the next pregnancy

Uterus: Reduction in Size

"After pains" are also effective in helping to return uterus to pre-pregnancy size Involution Term used to describe reduction in size of uterus postpartum Immediately postpartum uterus is about size of a __*grapefruit*__ Uterus will never return "all the way" to pre-pregnancy size

Following postpartum discharge teaching by the nurse, which statement by the client indicates an understanding of how to provide self-care?

"I should contract my buttocks before sitting or rising."

PP Activity

Avoid: Heavy lifting Excessive stair climbing Strenuous activity Encourage mom to sleep when baby sleeps Encourage ambulation

The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention?

Patient reports pain and warmth behild left knee

Two hours after a vaginal birth under epidural anesthesia, a client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which factor?

edema in the lower urinary tract area

clinical manifestions of endometritis

Fever higher than _*100.4*__ Degrees F. Tachycardia Chills Anorexia Nausea Pelvic Pain Uterine tenderness Foul smelling lochia Leukocytosis Fatigue Lethargy

clinical management of uterine atony

Firm massage of uterine fundus (_*1st*_ nursing action) Uterus will most likely feel "*boggy*_" Express any clots that may be in uterus Eliminate _*bladder*___ distention Medications IV Oxytocin IM Hemabate IM Methergine Cytotec Bimanual compression

Erb-Duchenne Paralysis: Clinical Manifestations

Flaccid arm with elbow extended & hand rotated inward Absence of Moro reflex on affected side Intact grasp reflex Loss of sensation over lateral aspect of arm

PP depression

More serious & more persistent than "Post Partum Blues" Depression that lasts past baby's first few weeks of life Intense fears, anger, anxiety, despondency Rarely disappear without outside help

Wound infections

Most commonly on C/S incision site May be on site of lacerations or episiotomies Clinical Manifestations: Tenderness Warmth Fever, if present will be low grade Remember REEDA?

Continuous Positive Airway Pressure

Needed if incubator or cannula are not sufficient Preset level of pressure is applied Can be administered via nasal prongs, face mask or ET tube An orogastric tube should be inserted for decompression of the stomach

Ammorrhea

Needs thorough physical examination May be caused from: Pregnancy (most common cause of secondary) Congenital anomalies Hormone imbalances Hypothyroidism/Hyperthyroidism... Eating disorders Excessive exercise Emotional stress Medications

*The 5 P's for Sexual History*

Nurse needs to identify women at risk... Include questions about sexual history using 5 P's: Partners Prevention of Pregnancy Protection from STIs Practices Past History of STIs

Breast Feeding Mothers

Observe feeding technique with mother Assist as needed Encourage her to wear a well-fitting supportive bra continuously Keep breasts clean - no _*soaps*__! Educate!!

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma.

A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply.

Talks and coos to her son. Cuddles her son close to her.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization.

The nurse is caring for a primipara who gave birth 12 hours ago. The client says, "Look at all of the beautiful things my family brought for the new baby." The nurse should become concerned if the client has received which gift?

a pillow in the neonates crib

While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibits which symptom?

dysnea

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time?

firm fundus at the symphysis

During the fourth stage of labor, the client should be assessed carefully for

uterine atony.

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

A client with gestational diabetes had a cesarean birth because the fetus was determined to be large for gestational age. The nurse should assess for which postsurgical complications? Select all that apply.

wound-edge separation fever after the first 24 hours postpartum lochia odor purulent drainage from incision

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching?

"If you have excessive vaginal bleeding, massage your fundus and call the physician."

Factors effecting Parent-Infant Attachment

"Maternal-fetal" attachment behaviors—impact of a difficult pregnancy and/or birth experience Cultural beliefs or practices Family structure & functioning Contact during early "sensitive" period Prolonged contact after birth

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective?

"My menstrual flow should resume in approximately 6 to 10 weeks."

endometriosis diagnosis

1. painful intercource 2.heavy menstration 3.infertility Tissue responds with changes in hormone levels Bleeds into surrounding structures Causes: Unknown but some theories Retrograde blood flow out of uterus and thru fallopian tubes Immature cells from embryonic development persist into adulthood, lying dormant until eventually developing into ectopic endometrial tissue Metastasis thru lymph and vascular systems Diagnosis of Endometriosis: Accurate diagnosis only possible thru laparoscope to visualize pelvic organs

Uterine Atony

Accounts for > __*90*___% of all cases of Postpartum Hemorrhage Hypotonia of uterus Uterus is supposed to start contracting after placental separation & expulsion With uterine atony, uterus is flaccid Brisk venous bleeding occurs Dark blood MOST COMMON CAUSE OF EXCESSIVE POSTPARTUM BLEEDING MAINTAIN GOOD UTERINE TONE PREVENT __Bladder__DISTENTION Full bladder may push uterus up higher than it should be, making it difficult to contract If uterus is palpated higher than expected & deviated to _*always*___—always expect a full bladder Full bladder will lead to an increase in bleeding

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?

Administer pain medication per prescription.

A client one day post-cesarean birth requests pain medication, stating her pain is 8 out of 10 when the nurse enters the room to perform her shift assessment. Which action by the nurse is most appropriate.

Administer the ordered pain medication, explaining to the patient that she will be back within the hour to examine her.

Effects of Substance Abuse:

Alcohol Tobacco Marijuana Cocaine Heroin Methadone See Table 35-4 on pg. 869 Summary of Neonatal Effects of Commonly Abused Substances

CNS Anomalies

Anencephaly Encephalocele Meningomyelocele Hydrocephalus

PP Contraception

Assess knowledge of & past use; (Note: Breast feeding is not considered a very effective method of birth control!!) - "mini" pill preferred if client is breast feeding & desires oral contraception

PP EXTREMITIES

Assess legs for edema, warmth, redness and pain (+ _Homans*_ SIGN) Clotting factors remain elevated during postpartum ↑ risk Thromboembolism due to: Hypercoagulable state Immobility Vessel damage Sepsis

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

Clinical/Nursing Management of Sepsis

Assessments Blood cultures, CBC, vital signs Treatments IV antibiotics Oxygen or other respiratory aids Breast feeding encouraged for protective antibodies Patient education/Discharge Planning

Hyperbilirubinemia

Bilirubin level in blood is increased Characterized by jaundice of the skin, sclera.. May be categorized as: "physiological" "pathological"

syphilis Primary Stage

Characterized by primary lesion Primary lesion is called a Chancre Painless, indurated lesion of penis, vulva, lips, mouth, vagina, and/or rectum Appears 5 - 90 days after initial infection Lasts 3-6 weeks Heals spontaneously

Skeletal Injuries: Fractured Clavicle

Clavicle is bone most often fractured during birth Frequent Cause: Shoulder Dystocia

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do?

Continue to monitor the client's vital signs.

Potential Hematologic Complication: Anemia

Due to: Slower production of RBC's due to immature bone marrow Will improve with maturation Fragile capillaries Impaired coagulation, including prolonged prothrombin & partial thromboplastin time Loss of blood due to frequent blood sampling

Location of the Fundus

Each day fundus will lower about 1 finger breadth Approximately 1 cm By 2nd week, uterus will be below symphysis pubis Uterus will be approximately at it's pre-pregnant size by 6th week postpartum _*breastfeeding*__ feeding woman contract more due to oxytocin release, so involution may be more rapid.

Treatment of Hyperbilirubinemia

Early feeding: Facilitates removal of bilirubin through stools Breastfed infants have increased incidence of jaundice Begins 2-4 days after birth Thought to result from decreased caloric & fluid intake before milk supply is well established Recommend breastfeeding within 1st few hours after birth then 10- 12 times per day

PP Perineal Changes

Edema & tenderness of perineum is to be expected Assess episiotomy incision Edges should be together Assess for signs of infection Healing should occur in 2-3 weeks

clinical management of wound infections

Education on prevention and signs/ symptoms Antibiotics Wound Debridement Wounds may be left open with a drain inserted Good hygiene

PP Temperature

First 24 hours: There may be a slight rise in temperature due to dehydration from labor Should not exceed 100.4F 3rd or 4th day postpartum: Expect temp to rise due to increase in vascular activity when milk comes in This fever should not last more than a few hours >100.4F after first 24 hours should be investigated According to Joint Commission on Maternal Welfare Postpartum infection is a major cause of postpartum mortality

PPUrinary Elimination

Following birth, woman should void within 4 hours Encourage her to void every 4 - 6 hours Palpate for bladder distention upon fundal & perineal checks May need to straight cath to empty bladder if she is unable May need to insert a foley catheter if she continues to have difficulty voiding

Extracorporeal Membrane Oxygenation (ECMO)

For infants with severe pulmonary dysfunction Cardiopulmonary bypass to oxygenate infant's blood Outside body through membrane oxygenator

The nurse is caring for a client who is 2-hours post-partum and experienced a fourth-degree vaginal laceration. Which intervention should the nurse teach the client is contraindicated at this time?

Frequent Kegel exercises

pp Documentation of Fundal Assessment

Fundus Firm, location Ex: FF@ -1 or FF@ u/1 Fundus boggy, firm with massage, location... Fundus boggy, does not firm with massage... Is bladder full? Is medication being administered? Amount of lochia? Any clots?

*Human Papillomavirus (HPV)*

Genital warts (condylomata acuminata) Most prevalent viral STI Incubation period 1-6 months Linked with cervical & vulvar cancer Typically from 1-10 warts at a time Cauliflower-like Most commonly seen in posterior part of introitus

Treatment of Fractured Clavicle

Gentle handling No other treatment Figure-eight bandage is appropriate for older children, but not recommended for NB

Clinical/Nursing Management: Apnea

Gentle stimulation O2 via bag & mask Apnea monitors Theophylline or Caffeine Sodium Benzoate May need to be on ventilator

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first?

Gently massage the fundus.

reproductive Bacterial Infections

Gonorrhea—often asymptomatic Chlamydia—often asymptomatic Syphilis Bacterial Vaginosis All are reportable communicable disease (except Bacterial Vaginosis) Healthcare providers are legally responsible for reporting all cases

After pains

Good thing! Usually will give Tylenol or Ibuprofen Will usually diminish in 2 to 3 days _*breastfeeding*__ will increase incidence

Endometeriosis Treatment

Goserelin (Zoladex) Gonadotropin-releasing hormone agonist Suppresses pituitary gonadotropin secretion FSH & LH stimulation declines Women may experience _*menopause*_ symptoms Zoledex initially causes increase of FSH & LH (Lupron is another GnRH) Endometrial Ablation: Procedure that destroys (ablates) the endometrium Ablation can be done by multiple ways, such as... Radiofrequency A balloon filled with saline solution that has been heated to 185'F Normal saline (heated free fluid) Electricity, using a resectoscope with a loop or rolling ball electrode Freezing

Chlamydia

Gram negative bacterium Chlamydia trachomatis Most prevalent STD in USA Occurring at a rate of 3 million new cases per yr Difficult to diagnose & complications are highly destructive Often asymptomatic Expensive to culture If not diagnosed or treated 40% will develop PID 1 in 5 become infertile

Collaborative interventions

HELP PARENTS: integrate birth experience: increases self-esteem meet their own needs (Maslow); include support systems, baby-sitting, etc. develop successful infant care skills & satisfying interactions by teaching (specific concrete demonstrations & suggestions), Role Model, reinforce positive behaviors

fundal:Uterus

Have bed flat to assess location Press "in & down" to find fundus Check often for firmness & location Should feel like a hard ball If boggy ---- _*massage it*_ it. When massaging fundus, provide support to lower segment To avoid inverting uterus.

syphilis Tertiary Stage

If left undiagnosed & untreated, will result in tertiary (latent) syphilis Asymptomatic 1/3 of patients will develop multiple organ complications *Cardiovascular, neurological, musculoskeletal*

*Reproductive Infections*

Include > 25 infectious organisms transmitted sexually Causes--personal & financial burdens Prevention Education? Identify risk factors Change risky behaviors Reduce # of partners Use condoms

Alcohol Related Neurodevelopmental Disorder (ARND)

Infants who are exposed to alcohol, but do not meet the criterion for ARBD Effects of ARND may include: Learning disabilities Behavioral problems Speech/ language problems Hyperactivity

endometritis

Infection of lining of uterus Most common postpartum infection Usually begins at placental site, but spreads to entire endometrium Incidence is higher after cesarean birth

Sexually Transmitted Infections (STI)

Infections primarily transmitted by sexual contact One of most common health problems in USA STI's --cause reproductive morbidity Complications--Preterm labor & low birth weight

Criteria for Physiologic Jaundice

Jaundice appears after 24 hours Disappears by end of 7th day Level should not exceed 12 mg/100ml If the above criteria does not fit, the jaundice may be due to a more serious "pathologic" problem

Preterm Infant: Appearance

Little subcutaneous fat Head disproportionately large compared with chest Skin is ruddy looking Minimal vernix Lanugo is abundant Few or no sole creases Ear cartilage is immature Reflexes may be absent sucking & swallowing Cry is weak & high pitched

Herpetic Infection

Localized symptoms Painful lesions that progress from macules to papules to vesicles... Typically last 4-15 days before crusting *Systemic* Symptoms: Typically appear 3-4 days after lesions Fever, malaise, headache & photophobia *Suppressive therapy* Famvir, Valtrex, Zovirax (Acyclovir)

Prevention: Apnea

Maintain body temperature Gentle handling-- to avoid fatigue Avoid vagal stimulation Observe after feedings Full stomach will put pressure on diaphragm

Potential Complication: Heat Loss

Major problem for Preterm infant due to: Immature temperature regulating center in brain Minimal stores of glycogen in liver Minimal insulating subcutaneous fat Limited stores of brown fat No shiver response Due to absent reflex in capillaries

Exposure to Marijuana

Marijuana crosses placenta Has been associated with: Increase incidence of Meconium Staining Low birth weight Tremors More studies are needed

Congenital Anomalies: In General

Most common congenital anomalies: Cardiac, Musculoskeletal, Neurologic Incidence of congenital anomalies is greatest among LGA babies IUGR/LGA infants occur in Diabetic moms with what? Uncontrolled blood glucose levels

Infants of Diabetic Mothers (IDM):

Most complications caused by uncontrolled blood glucose levels Most congenital anomalies occur during first 8 weeks after conception Occur in 7 - 10% of all IDM

Gonorrhea

Neisseria gonorrhoea (Gram negative organism) Primarily spread by genital to genital contact Also be spread by oral-genital & anal-genital May be transmitted to newborn during birth

pp Oxytocin

Oxytocin stimulates "let down" reflex Milk ejection Let Down Reflex Causes? Tingling sensation Increased uterine cramping Increased lochia Release of milk out of both breasts

Nutritional Complication:

PT NB have an accelerated metabolism rate Due to stress, repair & growth Need more calories/kg in diet Preterm: 115 - 140 calories per Kg Term: 100 - 110 calories per Kg Often unable to breast or bottle feed Gavage, gastrostomy or parenteral feedings

RhoGAM

Passive Immunization Provides passive antibodies, so that mom's body won't create it's own This will protect "future" pregnancies.

Prevention of PV-IVH

Recognize events that may *precipitate*__ hemorrhage Maintain O2 levels Avoid rapid IV infusions Monitor BP closely Monitor for pneumothorax Position infant with HOB elevated slightly

Treatment: Bacterial Vaginosis

Recommended antibiotic: Metronidazole (Flagyl) Sexual partners do NOT need to be treated Patient Education Avoid douching Avoid hot tubs Change wet bathing suits soon Avoid tight clothing

Exposure to Alcohol

Referred to as "Alcohol Related Birth Defects (ARBD)" Previously referred to as FAS ARBD is based on three criterion: Prenatal /Postnatal growth retardation CNS malfunctions Some degree of IQ deficit, ADD, diminished fine motor skills, poor speech Craniofacial features Microcephaly, small eyes, short palpebral fissures, thin upper lip, flat midface

pelvic inflammatory disease: risk factors

Risk Factors: STI's Partner with untreated urethritis Recent IUD insertion Douching Multiple sex partners

PP Immunizations

Rubella Vaccine Administered to mom's whose rubella titer is less than 1:10 Must not become pregnant for 3 months following the vaccine Tdap

When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia?

Rubra, then serosa, then alba

clinical manifestations of pp Depression

Same as for depression that is not obstetrically related Mom feels added guilt of being an inadequate parent Often feels a resentment & abnormal jealousy toward baby Often have intense food cravings & weight gain Irritability that sometimes escalates to violent outbursts or crying uncontrollably

pp Colostrum

Secreted during pregnancy & for 2-4 days after birth Yellow, creamy appearing fluid Thicker than mature milk Contains more protein, fat-soluble vitamins & minerals High levels of immunoglobulin

treatment of Neonatal Abstinence Syndrome

See textbook for Care of NAS Infant Interventions: __*decrease*__ stimuli Provide adequate nutrition Weigh daily Promote positive maternal-infant bonding Correct hydration/ electrolyte imbalances Pharmacologic Treatment to include... Phenobarbital, Diazepam, Methadone, Morphine

PP Vital Signs

Temperature: 97.1˚ (36.2˚) - 100.4˚ (38˚) Pulse: 50 - 70 b/m Respirations: normal or 🡻 Blood pressure: normal or slight 🡻

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault.

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires.

One day after a client gives birth, the nurse performs a postpartum assessment. Which finding indicates a need for further evaluation?

The patietn reporting uterine tenderness

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally?

The uterus is descending at the rate of one fingerbreadth per day.

A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus.

The uterus would be palpable at the level of the umbilicus between 4 and 24 hours after birth. The fundus of the uterus should be palpated for position and firmness.

Methadone

Therapy for heroin addiction Synthetic Opiate Questionable regarding benefit in pregnancy: Methadone withdrawal resembles heroin withdrawal, but tends to be more severe & prolonged Incidence of seizures is higher with Methadone withdrawal

s part of the postpartum follow-up, a nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information which assessment would the nurse make?

This is expected behavior for a client 3 to 7 days postpartum.

Thromboembolic disease

Thrombosis: Blood clot(s) inside blood vessel Incidence & etiology: 1 in 1000 - 1 in 2000 Major causes: Venous stasis Hypercoagulation

Neonatal Infections: HIV/ AIDS

Transmission can occur from: Prenatal Transmission, During Birth, Through Lactation Rate of transmission can be decreased from 12-40% to <1%: Treating HIV infected pregnant woman with AZT (Zidovudine) during pregnancy & intrapartum Treating infant for first 6 weeks of life with AZT Schedule an elective C/S

PPUterus

Two main goals for uterus postpartum: Sealing of _*placental* site _*reduction*_in size Sealing of Placental Site: After delivery of Placenta, bleeding will occur by large uterine vessels at placental site Uterus will begin to contract immediately after delivery of placenta. These contractions are called "__*after*-pains" Contractions cause retraction of uterine muscle fibers This clamps down on blood vessels & controls bleeding Thrombi form over vessels First _*hour*_ postpartum is most dangerous for hemorrhage b/c _*thrombi*_ have not formed over placental site yet The part of endometrial lining that was NOT under placenta will slough off This endometrial tissue will be ready for implantation in _*3*_ weeks! Endometrial tissue under placental site will be ready for implantation in _*6*_ weeks

Physiologic Jaundice

Type of Jaundice that is due to liver immaturity Occurs in about 50 - 60% of all full-term newborns 80% of all pre-term infants Usually a benign condition, but can become dangerous!

Lochia Assessment

Type, amount & consistency of lochia is important to assess to determine: Early postpartal hemorrhage-within 24 hours of birth Late postpartal hemorrhage-> 24 hour, < 6 weeks PP Subinvolution of uterus Watch for persisting or re-occuring Lochia Rubra May need to weigh perineal pads: 1 gram = 1 ml of blood See Box 20-1 on pg. 475 Ways to distinguish between lochia & nonlochia discharge See Emergency Box, page 487 Hypovolemic Shock; signs/symptoms & interventions

mastitis: breast infection

Typically... Caused from Staph Aureus Caused from nipple fissure Usually unilateral Will occur after mature milk comes in Usually between week 2 & 4 postpartum

Mechanical Ventilation

Used for severe hypoxemia or severe hypercapnia Ventilator settings are individualized to infants needs May be set to deliver a specific amount of O2 Or, to initiate ventilation if baby has periods of apnea

PP fever

Usually First Symptom A fever over 100.4 degrees F. for two consecutive days, during first 10 days postpartum Don't count any fevers that occur during first 24 hours postpartum

Causes of PP hemorrhage

Uterine Atony Lacerations Retained Placenta Inversion of Uterus Subinvolution of Uterus

clinical management of cystocele

Vaginal Pessary Surgical repair Surgical shortening of pelvic muscles to provide better support for bladder

clinical management of rectocele

Vaginal Pessary not usually effective Small rectocele may not need treatment High fiber diet Adequate fluid intake Stool softeners/Laxatives Surgical repair for large rectoceles

PDA: Clinical/Nursing Management

Ventilator Support Fluid restriction Diuretics Indomethacin Prostaglandin Inhibitor Causes PDA to constrict Surgical closure of PDA

PP Blood Values:

WBC count: @ 20,000 - 25,000 postpartum Hemoglobin & Hematocrit: Difficult to interpret during first 48 hours due to shifting of blood volume Values should be approximate to pre-pregnancy values within 2 - 6 weeks

Potential Cardiovascular Complication: Patent Ductus Artiosus

What causes the ductus arteriosus to close? May not be able to close due to inadequate pressure PDA increased blood volume to lungs pulmonary congestion, increased respiratory effort & carbon dioxide retention

Assessment of Lochia Discharge

What if there are clots? What if there is a foul odor? What if there is blood pooling under the patient' s buttocks?

PP REEDA

What would you think if you saw a bottom that looked like this?!

Respiratory Distress: Clinical Manifestations

Wheezing Effort Tachypnea Flaring (nasal) Retractions Oxygenation Grunting __hypothermia/hypoglycemia____________ Respiratory Distress

PP Vaginal Changes

Will be bruised & edematous immediately after delivery May have small superficial lacerations Diameter will return to "almost" the prepregnant diameter within 6-8 weeks Kegel's exercise may help!

PP Weight Loss

Will lose about 12 pounds with delivery Additional five pounds due to rapid diuresis & diaphoresis first 5 days At six weeks she will not usually lose anymore Except with effort!

In developing a plan of care for the client who has just given birth to a 7-lb (3,175-g) baby, the nurse reviews her prenatal, labor, and birth records. Which data in the client's record would alert the nurse to the possibility of a problem?

perineal laceration

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage?

placenta previa

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?

placing as much of the areola as possible into the baby's mouth

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor?

release of oxytocin during the breastfeeding session

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client?

risk for infection

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client?

risk of infection

Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium?

rubella counseling and immunization with live rubella virus vaccine

While the nurse is palpating the breasts of a client who is breastfeeding her 12-hour-old neonate, what is an expected finding?

soft breasts that are not tender to touch

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?

softening of the stool

A client with a past history of varicose veins has just given birth to her first neonate. The nurse suspects that the client has developed a pulmonary embolus. Which findings support the nurse's suspicion? Select all that apply.

sudden dyspnea diaphoresis confusion

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action?

tachycardia and hypotension

A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period?

taking in

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment?

two perineal pads soaked with blood within 30 minutes

The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)?

urinary output of 25 mL in the past hour

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony

Common Diagnostic Test: reproductive

vaginal culture

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains?

G3, P3 client who is breastfeeding her infant

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next?

Administer a prescribed mild analgesic.

The nurse plans care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first?

a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm

A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?

washing the hands and wearing gloves

After instructing a primiparous client about episiotomy care, which client statement indicates successful teaching?

"I wipe front to back in a blotting motion"

Indirect Coomb's vs. Direct Coomb's

DIRECT COOMBS: Looks for RBC's coated with antibodies in Newborn's Sample INDIRECT COOMBS: Looks for circulating antibodies in Maternal Sample

childbirth trauma

Uterine Prolapse Cystocele Rectocele Genital Fistulas

PP hemorrhage: Retained Placenta

**Most common cause of _*subinovolution*_ Non-adherent Retained Placenta May be a very small piece of amniotic membrane, or a larger part of placenta Despite size of fragment, uterus will respond by trying to "wash" it out. Treatment.... Intrauterine exploration Possibly D& C

Herpes Simplex Virus

*One of most common STI's* 50 million persons in USA HSV has 2 subtypes HSV1 Transmitted non-sexually Fever blisters HSV2 Usually transmitted sexually Usually vaginal

syphilis Secondary Stage

*Systemic* 6 wks - 6 mo after chancre is seen Maculopapular rash on palms & soles Fever Alopecia Headache Lymphadenopathy

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend?

every 2 to 3 hours for the first 48 hours

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2 to 4 days

*Risk Reduction Measures*

Abstinence of activities with fluid exchange Avoid: Practices that increase tissue damage Direct contact with lesions Increased # of partners Knowledge of partner's sexual history Vaccinations

A client gave birth to a neonate with spina bifida. The client was informed during her pregnancy that this situation could occur. The nurse giving a report on the client states that the client's decision to continue with the pregnancy was selfish and that the neonate will suffer. How should the nurse proceed in caring for this client and her neonate?

Accept the client's decision and care for her as any other client.

Potential Gastrointestinal Complication:Necrotizing Enterocolitis (NEC)

Acute inflammatory disease of gastrointestinal mucosa May result in ulcerations & perforation May occur in 2 - 5 % of NB in NICU's May have up to a 40% mortality rate

*Common Treatments for ALL Bacterial Infections*

Antibiotics *Both partners* must be *treated* even if asymptomatic (except bacterial vaginosis) Abstinence during treatment

PP Infections

Any infection of genital canal that occurs within 28 days after miscarriage, induced abortion or childbirth Endometritis Wound Infections Urinary Tract Infections Mastitis Occurs in USA 2% of vaginal birth 10- 15% of Cesarean Births

A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention?

Applying a breast binder to support the breasts

Recurrence of Ovulation/ Menstruation

As soon as placenta is delivered, estrogen & progesterone will decrease Hormone levels will be at pre-pregnant levels within one week Decrease in estrogen & progesterone stimulates FSH release & return of ovulation Ovulation will likely precede menstruation Therefore a lack of menstrual return does not mean the woman cannot become __*PRegnant again!

pp OVULATION

BREASTFEEDING ↑ PROLACTIN levels suppress ovulation in breastfeeding Levels effected by frequency, duration of feeds, as well as supplement use Menses return-highly variable BOTTLE FEEDING ↓ Prolactin levels Menses return Average is ______ wks pp, usually by 3 months Ovulation occurs _before__ the menses

pp Emotional changes

Baby Blues Postpartum Depression Mild Moderate Severe Postpartum Psychosis

Uterine Fibroids

Benign neoplasms of smooth muscle origin Most common form of pelvic tumor 1/ 4-5 women > 35 yrs of age

Exposure to Cocaine

CNS Stimulant Acts as a peripheral sympathomimetic Effects to fetus are secondary to maternal effects High blood pressure Vasoconstriction Infants may exhibit: Poor suck, high pitched cry, rigidity, irritability, irregular sleep patterns, inability to be consoled, hypersensitivity to sound/noise

Signs of Bilirubin Encephalopathy

CNS depression or excitation, which will include: Decreased activity Lethargy Irritability Hypotonia Seizures

Pelvic Inflammatory Disease

Can lead to serious consequences including: Infertility Ectopic pregnancy Abscess formation Chronic pelvic pain Large # of ectopic pregnancies occurring every year are due to PID Diagnosis Difficult to diagnose Laparoscopy would confirm diagnosis

incomplete uterine inversion

Cannot be seen, but can be felt through a vag exam

uterine prolapse

Caused by congenital or acquired weakness of pelvic support structures Mild or complete In Complete Uterine Prolapse cervix & body of uterus protrude through vagina

Facial Palsy

Caused by pressure on facial nerve during birth Clinical Manifestations: Side remains "flattened" Eye remains open Forehead will not wrinkle Mouth will appear distorted with crying Permanent paralysis is rare Will usually resolve in few days after birth Treatment: Assist with feeding Prevent damage to cornea as result of an open eye

Pt teaching to prevent DVT

Change position frequently Do not sharply flex legs Do not massage calf How to put on elastic stockings

A multigravida 30-year-old woman has given cesarean birth to a healthy term neonate due to an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's urinary catheter and observes that the client's urine is slightly red-tinged. What should the nurse do next?

Contact the client's health care provider (HCP) for further orders.

Other proven effects of Cigarette Smoking

Deficits in growth Deficits in intellect & emotional development Poor auditory responsiveness Increased fine motor tremors Hypertonicity Increase incidence of SIDS deaths

Rubin's Phases

Dependent: taking-in first 1-2 days focus: self & own needs dependent excited, talkative desires to review birth experience

Management of Dysmenorrhea

Depends on severity Treatment alternatives include: Heating pads/Hot baths Massaging lower back Pelvic Rock Exercises/ Yoga Increases vasodilation Releases endogenous opiates Suppresses prostaglandins Meditation Decrease salt & refined sugar intake 7 - 10 days before expected menses May reduce fluid retention Natural diuretics Asparagus, cranberry juice, peaches, watermelon Medications: Prostaglandin Inhibitors Oral Contraceptive agents Decreases prostaglandin release

HPV Treatment

Difficult to treat Topical Treatment: Trichloracetic Acid (TCA) Cryotherapy Electrocautery Laser Therapy *Vaccine—Gardasil* Approved by FDA for males & females ages 9-26 *Ideally, vaccination should occur before youth become sexually active*

Pharmacological Treatment of PMS/PMDD

Diuretics Progesterone replacement SSRI's Prostaglandin inhibitors Low dose BCP's If not planning a pregnancy

A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next?

Document these expected behaviors of the taking-in period.

PP Cardiovascular

Due to increase in blood volume, signs of hypovolemic shock are not usually evident in women with normal amount of blood loss after delivery Signs may be delayed in women who have a heavy blood loss

Hemorrgagic (hypovolemic shock)

Emergency situation Perfusion of organs severely compromised *Death may occur* Physiologic compensatory mechanisms are activated Signs of shock may not appear until 30% to 40% of blood volume is lost Medical management Restore circulating blood volume Treat cause of hemorrhage Nursing interventions Frequent assessment Monitoring of vital signs Accurate intake & output Fluid or blood replacement therapy via IV Ensure patent airway—administer O2

Non-Nursing Mothers

Encourage a supportive, well-fitting *bra*_, continuously until lactation is suppressed: Usually within 5 - 7 days Ice packs applied to axillary area bilaterally for 20 minutes, 4x a day Avoid any _*stimulation*__ of her breast Avoid heat to breasts Avoid having shower water hit her front side Cabbage leaves

Management of Fibroids

Exogenous estrogen makes it worse Size will regress with menopause Leuprolide (Lupron) Gonadotropin releasing hormone May be used to shrink size of fibroid Hysterectomy (?BSO also)

The nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?

Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg

Viral STI's - Hepatitis

Hepatitis A virus (HAV) Acquired primarily through fecal-oral route Influenza-like symptoms Vaccination is most effective means of preventing HAV transmission Hepatitis B virus **Most threatening to fetus & neonate Transmitted parenterally, perinatally, orally (rarely), & through intimate contact vaccination series Hepatitis C virus Most common blood-borne infection in USA Responsible for 50% of cases of hepatitis 2.7 million people are now chronically infected New curative drug approved in 2017--Mavyret Risk factor for pregnant women is history of injecting intravenous drugs

clinical management of mastitis

Inflammatory edema & engorgement Obstructs flow of milk in a lobe Starts localized, then will spread to be a generalized infection Fever & Chills Breast tenderness Malaise Redness & axillary adenopathy may develop Prevention through education Antibiotics Breastfeed or use a breast pump every 2-4 hours Heat/ cold therapy Hydration

PP:Fourth Stage of Labor

Initial 1-2 hours after birth of placenta Body systems begin to stabilize Maternal organs undergo initial readjustments to non-pregnant state VS Q 15 min X1 hour, frequent physical assessment Tremors/ "shakes" ; Hungry & Thirsty GREATEST RISK FOR _*postpartum hemmorrage*

NSG interventions DVT

Inspect & palpate affected leg Palpate peripheral pulses Compare leg circumferences Monitor for s/s of pulmonary embolus

Treatment: Erb Duchenne Paralysis

Intermittent Immobilization With use of brace, splint, pinning infants sleeve to mattress Should immobilize infants arm for 2-3 hours, then release. Proper positioning ROM exercises Not to start until after 10 days so that you won't further aggravate brachial plexus nerve

Major Causes of NEC:

Intestinal Ischemia From hypoxia at birth Bacterial or viral infection Due to immature immune response Immature gut Decreased amount of gastric acid & underdeveloped protective intestinal mucin layer

Clinical Manifestation: Fractured Clavicle

Limited movement of arm on affected side Crepitus over bone Absence of Moro Reflex on affected side

Phototherapy

May use... Bili-lights Phototherapy blanket Bili-bed All types use systems use light therapy that will breaks down bilirubin in skin into substances that can be excreted in feces & urine

PP Medications

Medications are often given after delivery to facilitate uterine contractions Pitocin IV Methergine IM Do not give with hypertension Hemabate IM Prostaglandin F Contraindicated in patients with asthma

ECMO

Membrane Oxygenator serves as a artificial lung Allows infants lungs to mature and/or heal ECMO requires anticoagulation therapy so that blood does not clot in tubing

Potential Complications: Retinopathy of Prematurity (ROP)

Ocular disease that can lead to blindness Due to vasoconstriction of immature retinal blood vessels High oxygen concentrations cause vasoconstriction When oxygen is d/c'd, then dilation of vessels takes place Causes capillary hemorrhages, scarring & retinal detachment in some cases Process may take 5 months

lacreations

Of cervix, vagina and/or perineum May appear as a slow trickle of blood, oozing or frank hemorrhage Suspect lacerations if bleeding continues despite a firm, contracted uterine fundus

Anemia: Clinical Manifestations

Pale skin Increase in apneic periods Lethargy Tachycardia Poor weight gain Low H/H levels

ROP

ROP is Not reversible Prevention is key Preterm babies need frequent ophthalmologist visits Treatments that are tried: Laser photocoagulation Vitamin E therapy Decreasing ambient light

LOCHIA

RUBRA (red) day 3-4 SEROSA (pink) until day 10-14 ALBA (white) 2-6 weeks after birth Odor is "fleshy", like menses If offensive odor → may indicate __*infection*__ Less amount after C/S May ↑ with activity or ambulation May pool in vagina if woman lies down, then "gush" When the lochia flow stops, cervix is considered closed Usually about 3- 6 weeks This is when risk of infection is considered to be decreased. Sexual intercourse

PV-IVH: Common Precipitating Events

Rapid birth Hypoxia IV infusions Ventilation Pneumothorax

endometriosis

Tissue responds with changes in hormone levels Bleeds into surrounding structures Causes: Unknown but some theories Retrograde blood flow out of uterus and thru fallopian tubes Immature cells from embryonic development persist into adulthood, lying dormant until eventually developing into ectopic endometrial tissue Metastasis thru lymph and vascular systems Diagnosis of Endometriosis:

PP hemorrage: inversion of uterus

Turned Inside Out Life threatening May be a partial or complete inversion

BONDING

Unidirectional parent 🡺 infant Develops rapidly hours after birth Facilitated by physical contact "Falling in love"

Subinvolution_

Uterus that does not return to a non-pregnant state Most commonly caused from: _*retained placental fragments or infection* Late Post Partum Bleeding 24 hours after deliver <6 weeks postpartum Involution Process may be delayed with following: Excessive analgesia use during labor Exhaustion from prolonged or difficult labor Multiple gestation Grand multiple parit

complete inversion

Uterus will be inverted & will protrude 20 - 30 cm outside vaginal opening

Musculoskeletal Anomalies

Weakness & deformity of lower extremities Malformation of hip joint

Mom's Breast Milk Preferred

Breast milk can be provided via bottle, OG or G- tube OG-Tube is preferred over NG b/c infants are nose breathers

Differentiating bruises from Mongolian spots:

Blanch skin with 2 fingers If skin color blanches, it is Mongolian Spots If skin doesn't blanch, it is petechiae or bruising

clinical manifestations of rectocele

No symptoms when laying down Minimal symptoms if small If really large, rectocele may actually protrude outside vaginal opening when woman stands up May have difficulty with bowel movements

Siblings & Extended Family

Parental education and preparation Key for sibling: "Parents should continue to show love, concern & include the sibling in care of the baby" Formal classes for siblings & grandparents

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate?

The client needs application of an ice pack.

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area.

A client is recovering in the labor and delivery area after giving birth to a 6-lb, 3-oz (2,813 g) newborn. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?

a vaginal laceration

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

orange juice

Diagnosis: PDA

X ray: Pulmonary Edema Enlarged Heart Hepatomegaly Echocardiography: View blood shunting across PDA

diagnosis of endometriosis

Blood Cultures Intracervical or Intrauterine bacterial cultures Clinical Management of Endometritis... IV, broad spectrum antibiotics Hydration Rest Pain relief Assess lochia, vital signs, etc

PP Cardiovascular System

Blood that was shunting through uterus & placenta will suddenly go into maternal systemic circulation immediately after birth of placenta CO is increased Would this be difficult on woman with heart issues? Decreases rapidly for first 2 weeks postpartum Returns to normal within 6 weeks

Gastrointestinal System

Bowel movements may be difficult due to: Sluggish peristalsis Episiotomy Edematous perineal area Hemorrhoids Stool softeners are often prescribed.

Peripheral Nervous System Injuries: Erb-Duchenne Paralysis

Brachial paralysis of upper arm Most common type of paralysis associated with difficult birth Caused from: Stretching or pulling _*shoulder*_ away from shoulder

Preterm Complication: Respiratory Distress: causes

Causes: _Lower_ # of functional alveoli Deficient Surfactant Levels Smaller lumen in respiratory tracts Weak or absent gag reflex Immature capillaries in lungs

PP Cervical Changes

Cervix remains open Allows about two finger insertion during first 4-6 days By end of 1st week, will allow insertion of about a fingertip Appearance & shape of cervix will be forever changed Slit appearance, instead of round

PP increased infections with

Cesarean Section Prolonged Rupture of Membranes Prolonged Labor Internal maternal & fetal monitoring Bladder catheterization Multiple SVE Retained Placenta Episiotomy or Lacerations

Potential Respiratory Complication: Apnea

Pause in respirations longer than 20 seconds with accompanying bradycardia Common in preterm babies due to: Fatigue Immature respiratory mechanisms

Weaning from Oxygen Therapy

Weaning will occur in a slow, step format For example: ECMO - Mechanical - CPAP - hood - nasal cannula Many preterm infants are d/c'd home on O2 via NC

Prevention of NEC:

Breastfeeding Nonnutritive Sucking Reversal of perinatal asphyxia within 30 minutes After 30 minutes of hypoxia, body compensates by redistributing blood to essential organs

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain."

The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The nurse begins the catheterization process, and the client states, "I forgot to tell the nurse I get hives to betadine." The nurse should take which steps in order of priority from first to last? All options must be used.

Clean povidone-iodine from client's vaginal area. Notify the health care provider (HCP) prescribing catheterization. Document the incident. File an incident report.

PP Hemorrhage

Shortened hospital stays increase the potential for post partum hemorrhage Defined as: A loss of >_*500*_ ml after vaginal birth A loss of >_*1000*_ ml after a C- Careful _*Assessment*_is important! First _*Hour*_ postpartum is most critical Highest risk for hemorrhage

pp Blood Pressure

Should be same as in the THIRD trimester BP associated with hemorrhage or hypovolemia (late sign) BP pp onset of PIH or from excessive oxytocin Watch for _orthostatic hypotension

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?

The client will demonstrate self-care and infant care by the end of the shift.

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect?

dizziness

Fibroids: Signs & Symptoms

dysmenorrhea heavy bleeding painful sex fertility issues enlarged lower abdominal pain preg. complications

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor?

overdistention of the uterus from hydramnios

Following a cesarean birth, what should the nurse do first?

palpate the fundus

The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason?

to contract the mother's uterus

A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply.

"My fertility can return as early as 21 days after my baby's birth." "I have the hospital phone number if I have any questions." "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." "I know if I get fever or chills or change in lochia to call the health care provider." "I will continue my prenatal vitamins until my postpartum checkup or longer."

clinical manafestaions of uterine prolapse

"pulling", "dragging" sensation "heaviness" sensation Feeling of Pressure Fatigue Low back ache Stress Urinary Incontinence Kegel Exercise Several times a day to increase muscle strength Pessaries Supports uterus & holds it in position Hysterectomy if all else fails

The nurse is caring for a client with a diagnosis of early postpartum hemorrhage. Which would not be a priority action at this time?

Assess the number of perineal pads used during the past shift.

perineal lacerations are defined as:

1st Degree Skin & structures superficial to muscle 2nd Degree Through muscle of perineal body 3rd Degree Through anal sphincter muscle 4th Degree Involves anterior rectal wall

Vaginal Infections--Yeast/Candidiasis Infection

2nd most common type of vaginal infection Not an STI Can be transmitted to a partner thru sexual activity only if partner has a favorable environment for growth Such as in Diabetic patients

adherent retained placenta

Abnormal adherence of entire placenta at implantation Thought to be from an abnormal endometrial layer & "no zone" of separation between placenta & uterine lining Attempts to remove placenta will be unsuccessful May result in tearing of cord, placenta or uterine lining Treatment: __*Surgical*___ removal

Clinical Manifestations of NEC:

Abdominal distention Vomiting (bile or blood) Bloody stools Abdominal tenderness Erythema of abdominal wall Generalized symptoms such as hypotonia

RH Immune Globulin

All RH negative moms should receive RhoGAM within 72 hours after delivery of a RH positive baby. If pregnancy ended in a miscarriage, ectopic pregnancy..., she will also need to receive RhoGAM. Rh + blood has a particular antigen that Rh- blood does not have If mom's blood is exposed to that antigen, it will create antibodies in defense Just as it would with any other foreign object Antibodies will cause hemolysis of fetal RBCs Causing Hemolytic Anemia

Kernicterus

Also called Bilirubin encephalopathy Caused by deposits of bilirubin in brain Indirect bilirubin is highly fat soluble Will pass blood brain barrier May cause necrosis of brain neurons Exact level of serum bilirubin required to cause damage is not known Some texts will say that levels above 20 -25 mg/dl places full term infant at risk Preterm babies will develop problems with much lower levels (12mg/dl)

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often.

Clinical management DVT

Analgesics (NSAIDS) Elevation of affected extremity Rest TEDS Stockings Localized heat application Anticoagulant Therapy... Heparin IV Lovenox SQ Oral Anticoagulant Therapy

Neonatal Infections: Group B Streptococcus

Bacterial Infection Treated with antibiotics such as Gentamycin, Ampicillin or Penicillin If detected or suspected in the pregnant/ laboring woman, she will be treated with PCN _*during labor*__ Contracted by: Birth canal Baby to baby in nursery If staff is not washing their hands between caring for babies Babies who contract this infection are categorized into: Early onset Illness Late onset Illness

Perineum

Check perineum when checking lochia May be best to have her lay on her side & look from back Check for: Swelling Hematoma formation Episiotomy (REEDA) Presence of hemorrhoids Apply ice bag to perineum after delivery Apply ice for 20 minutes, off for 10 minutes Usually need to do this for first 24 hours Encourage use of Peri bottle Use after voiding to keep clean & to promote comfort

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep-breathing exercises

*non-nutritive*_ Sucking

Gavage or parenterally fed Pacifier is provided during feeding times May improve oxygenation & decrease energy expenditure (less restlessness)

Exposure to Heroin

Heroin crosses placenta Increase incidence of stillbirth, premature births, low birth weight, meconium aspiration, neurobehavioral problems, high pitched cry, seizures... No increase in congenital anomalies The baby will experience "withdrawal symptoms" If the mom stops using while pregnant, fetus will go through withdrawal Can lead to miscarriage or fetal death

most common causes of uterine atony

High Parity Polyhydramnios Macrosomic Fetus Multifetal gestation Use of Pitocin Prolonged labor

Viral STI's - HIV

Human immunodeficiency virus (HIV) Heterosexual transmission now most common means of transmission in women Estimated that 26% of new infections occur in women Transmission of HIV occurs primarily through exchange of body fluids Seroconversion in 6 to 12 weeks Severe depression of cellular immune system associated with HIV infection characterizes AIDS

clinical management of pulmonary embolism

IV Heparin until symptoms resolved Oral Anticoagulant Therapy follows Heparin & Warfarin are both safe if breastfeeding Warfarin is teratogenic if she becomes pregnant

Prognosis of Erb Duchenne Paralysis

If cause is edema or hemorrhage: Prognosis is good Recovery expected in @ 3 weeks If cause is tear of nerve: Prognosis is poor to fair Healing, if it does occur, will occur within 3-6 months If healing doesn't occur within 2 years, prognosis is poor Little of no function will return

*Herpes & Pregnancy*

If initial infection happens near time of delivery, there is high risk of transmitting virus to neonate Because it is systemic If tingling is felt, or lesions are present near time of delivery, a *C/S will be performed* If they have a history of herpes: May deliver vaginally if no tingling/ lesions Do not forget Standard Precautions

Pathologic Jaundice

Jaundice that does not meet expectations of normal "physiologic jaundice" Physiologic Jaundice... Appears after 24 hours & disappears within 7 days Bilirubin level does NOT exceed 12mg/dl in term infants or 15md/dl in preterm infant If pathologic jaundice is left untreated, can result in... Sensorineural hearing loss Mild cognitive delays Kernicterus

A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation?

Limited parent-neonate contact immediately after birth

dysmenorrhea (menstrual cramps)

Occurs a day before onset of menses & disappears by end of menses Prostaglandins are primary cause of pain Increases uterine contractility & decreases uterine blood flow (ischemia) More common in women: who smoke (possibly due to vasoconstriction) are obese (unknown)

clinical manafestaions of cystocele

Often asymptomatic "Something in my vagina" Urinary Frequency/ retention/ incontinence Recurrent UTI's Pelvic examination: *Bulging of anterior wall of vagina* Women with large Cystoceles may have to push up on sagging anterior vaginal wall in order to void

Clinical Manifestations: gonorrhea

Often asymptomatic: Diagnose? Diagnosis cannot be based on symptoms Diagnosis requires a culture Menstrual irregularities Greenish-yellow *purulent* endocervical discharge Chronic or acute severe pelvic or lower abdominal pain Vaginitis

Musculoskeletal

Only permanent change from pregnancy may be an increase in _*shoe*_size!!!! Abdomen protrudes when standing up due to relaxation Diastasis recti abdominis: separation of muscles Striae

Syphilis

Organism Treponema pallidum Pathophysiology Enters body thru small breaks in skin or mucous membranes Kissing, biting, oral-genital sex.... *Can be spread to a fetus via transplacental transmission during pregnancy*

Potential Neurologic Complications: Intracranial _*hemorrhage*

Periventricular-Intraventricular Hemorrhage (PV-IVH) Fragile capillaries rupture whenever there is a change in cerebral BP 15% of infants < 32 wks develop hemorrhages

clinical management of PP depression

Pharmacologic intervention Psychotherapy Possibly hospitalization

Birth Trauma

Physical Injury sustained by neonate during L&D May be avoided if high risk infants were identified during pregnancy Macrosomia, Hydrocephalus, CPD, Abnormal Presentation

Petechiae

Pinpoint hemorrhages Possibly from tight NC Good assessment & monitoring are critical!! Petechiae Benign if: "No new" petechiae appear Petechiae disappear within 2 days Danger Sign if: New Petechiae keep "cropping up" They do not disappear in 2 days May be Thrombocytopenia

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

PP complications

Post Partum Hemorrhage Thromboembolic Disease Postpartum Infections Childbirth Trauma Post Partum Depression

Potential Nutritional Complication: Difficulties with Intake

Preterm Infants Have Difficulty due to: Lack of coordinated suck/ swallow reflex Until 32 - 34 weeks Inability to suck due to congenital anomaly Respiratory Distress requiring ventilator Lack of O2 reserves Tendency for Necrotizing Entercolitis

Management of PID

Prevention is most important factor Education regarding STI prevention & management Broad spectrum antibiotic Bed rest in semi-fowlers position during acute stage Comfort measures Abstain from intercourse until treatment finished

Surfactant Administration

Prior to 32 - 34 weeks of gestation, NB lack surfactant Lack of surfactant causes: Atelectasis, decreased lung compliance & decrease in gas exchange Administered via ET tube Usually requires several doses Use of exogenous surfactant has proven to: Decrease time on ventilator Decrease O2 needed Increase survival rate

clinical management: inverted uterus

Requires immediate diagnosis & treatment Replace uterus within pelvic cavity Medications oxytocin/ methergine/ hemabate/ cytotec Broad spectrum antibiotics Treat shock

S/S of hypovolemic shock

Respirations_*rapid then shallow Pulses __*rapid then weak/irregular BP __*decrease (late sign) Skin__*cool, pale, clammy Urinary output__*decreases* LOC—lethargy—coma Mental status—anxiety—coma Central venous pressure__*lethargy-coma*

Premi Potential Complications

Respiratory Distress, Apnea, ROP Hematologic Anemia Cardiovascular PDA Temperature Heat Loss/Temp Maintenance Neurologic PV-IVH Nutritional Feeding Difficulties Gastrointestinal/ Hepatic Necrotizing Entercolitis Hyperbilirubinemia

Clinical Manifestations: Sepsis

Respiratory: Apnea/ Tachypnea/ Grunting Nasal Flaring/ Retractions Decreased oxygen saturation Metabolic Acidosis Cardiovascular: Tachycardia Hypotension Decreased Perfusion Central Nervous System: Temperature instability Lethargy/ Hypotonia Irritability/ Seizures Gastrointestinal: Decreased suck strength Increased residual/ abdominal distention Integumentary: Jaundice Pallor/ Mottling Petechiae

ppBreasts:

Should be soft & non-tender after delivery Will usually "fill-up" in 3rd or 4th day postpartum May become "Engorged"

What would you do for the patient with hemorrhoids?

Sitz Baths, Adequate fluid intake Stool softeners, Rectal Suppositories Topical Anesthetic Tucks Pads Topical ointment Avoid prolonged sitting Lay on her side as much as possible

Kangaroo Care

Skin to Skin Holding Provides an "external heat" source Studies have proven that Kangaroo Care: Enhances temperature regulation Maintains oxygen levels better Leads to fewer episodes of crying & apnea Increases heart rate Encourages developmental tasks

Birth Trauma may include:

Skin/ Hemorrhagic Problems Petechiae Skeletal Injuries Fractured Clavicle Peripheral Nervous System Injuries Erb Duchenne Paralysis Facial Palsy

Clinical/Nursing Management: NEC

Supportive __*NPO*_ Rest GI tract (give Parenteral Nutrition) OG tube for decompression Strict infection control Antibiotics Surgical resection may be necessary

Early Onset Illness: group b strep

Symptoms occur usually within 24 hours after birth Usually caused from maternal transmission during birth Results in severe respiratory distress

Neonatal Abstinence Syndrome

Term used to describe a set of behaviors exhibited by newborn who was exposed to chemical substances in-utero May have been exposed to substances such as... Amphetamines, Barbiturates, Benzodiazepines, Cocaine, Opiates/Narcotics (including heroin and methadone) Will occur during the first 24 - 48 hours See textbook: Signs of Neonatal Abstinence Syndrome Symptoms include: Jitteriness & Hyperactivity Shrill & persistent cry Yawn or sneeze frequently Hyperactive tendon reflexes Poor feeding & sucking Abnormal sleep cycles

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention?

massage the fundus

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony

S/S of pumonary embolus

chest pain coughing dyspnea tachypnea crackles

A primiparous client who gave birth to a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which assessment would be most important?

constipation

PP Urinary System

continued 🡹 risk for infection due to 🡻 tone & dilated ureters; - postpartal _*diuresis* (reversal of water metabolism of pregnancy), occurs within 12 hrs postpartum; also diaphoresis esp. at night. Body works to eliminate excess fluid voiding difficulties common

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement?

postpartum "blues"

A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider (HCP) because the mother should be evaluated further for which complication?

postpartum depression

The nurse makes a home visit to a primigravid client on the fourth postpartum day after birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing which condition?

postpartum psychosis

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate.

In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The client asks, "I've heard recommendations about when to resume intercourse have changed since my last baby. What are they saying now?" When should the nurse instruct the client that she can resume sexual intercourse?

when lochia flow and episiotomy pain have stopped.

PP Increased Cardiac Output:

🡻 pressure on Inferior Vena Cava 🡹 vasoconstriction from 🡻 progesterone 🡻 vascular bed (start of ) water reversal Extravascular water enters CV system Reason why woman can withstand an EBL of _*1000-2000*__ml!