ch 16 - nursing postpartum period

lacerations

1st - involves skin and superficial structures 2nd degree - extends through perineal muscle 3rd - extends through anal sphincter muscle 4th - continues through anterior rectal wall

light/small lochia

4" stain, 10-25 mL loss

moderate lochia

4-6" stain, 25-50 mL loss

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by:

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

if the fundus is higher than expected on palpation and is not midline, suspect

bladder distension

BUBBLE HE

breasts, uterus, bladder, bowel, lochia, episiotomy, hemorrhoids, emotions

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

*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.

scant lochia

1-2" stain, 10 mL loss

after birth the fundus descends

1cm/day and should be nonpalpable by day 10 right after birth it can be felt at level of umbilicus or right above it day 1 should be u/1 (1cm below) 1/u would be 1cm above which we don't want

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time?

Commonly, an *ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration.* An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the *first 24 hours* to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. *After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack* to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm?

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. The nurse should be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected?

During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, bleeding or discharge.

A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, the nurse notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this client?

Increased intake will rehydrate the client and decrease her skin temperature. The perception of increased skin temperature a short time postbirth is related to dehydration from the exertion of labor. Therefore rehydration should help to decrease skin temperature.

A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally?

Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum infection.

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. 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.

BM may not return to normal for up to

a week, but should have some kind of BM within 2-3 days stool softener/laxative can be prescribed to treat constipation if pt afraid of straining should be passing gas and should have bowel sounds in all 4 quadrants

assessment - breasts

any abnormalities to nipple could be caused by improper positioning of baby during breastfeeding engorgement - incomplete emptying - bilateral pain, hard, tender, taut "filling" - breasts become firmer with milk normals: colostrum-creamy yellow, foremilk-bluish white,milk-white

ensuring safety during ambulation

check BP first, elevate the head of the bed for a few minutes, have client sit on side of bed for a few minutes, help pt stand and stay with her, ambulate alongside and provide support, frequently ask how head feels, stay close to pt if pt feels light headed

bonding

close emotional *attraction to a newborn by the parents* that develops the first 30-60 minutes after birth - unidirectional, from parents to infant

attachment

development of a *strong affection from infant to significant other*

the episiotomy/perineum and epidural site could be

edematous and slightly bruised which would be normal assess it q8hrs *swollen bluish skin w/ severe pain = hematoma* *redness, swelling, drainage, discomfort, white line = infection*

prior to uterine palpation

empty bladder and auscultate bowel sounds

postpartum danger signs

fever >100.4, foul smelling lochia or change in color/amount, large blood clots, bleeding that saturates a pad in less than an hour, severe headaches, blurred vision, seeing spots, calf pain with dorsiflexion of foot, swelling/redness/discharge at site of episiotomy/epidural/ABD sites, dysuria/burning/incomplete emptying of bladder, SOB or dyspnea without exertion, depression or extreme mood swings

risk factors for postpartum infection

forceps, C/S, vacuum, DM, prolonged labor (>24hrs), indwelling catheter, anemia (hgb<10.5), multiple vag exams during labor, PROM > 24 hrs, manual extraction of placenta, compromised immune system (HIV)

infection control measures

frequent pad change, peri bottle, hand washing, wiping front to back

A woman yesterday gave birth to a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at birth. The nurse's priority is to assist the mother to:

grieve for the loss of the perfect baby. Grief is the response to loss. The process of mourning will take precedence over the mother's self-care in this initial period. The nurse will assess the mother to note her physical condition, but the mother will be focused on the child. The mother can be assisted to determine the appropriate time to see the child, and then attachment can be promoted.

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

alleviating breast engorgement while bottlefeeding

ice packs, tight supportive bra 24 hrs/day, mild analgesic (acetaminophen), AVOID: warm showers on breast, pumping/massaging breasts, sex

alleviating breast engorgement while breastfeeding

manual expression of breast before feeding, let newborn feed until it softens the switch, warmth, pumping/massage

uterine fundus should be

midline and feel firm, a boggy uterus is a sign of uterine atony, which can be related to bladder distension and can cause hemorrhaging

hematoma or infection

need to be reported ASAP

large/heavy lochia

pad is saturated within 1 hr of changing it

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus?

places a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion.

risk factors for postpartum hemorrhage

precipitous labor (<3 hrs), uterine atony, placenta previa or abruptio placentae, labor induction or augmentation, vacuum, forceps, C/S, retained placental fragments, prolonged 3rd stage of labor (>30 min~pushing out placenta), multiparity, uterine overdistension (large infant, multiples, hydramnios)

assessment 1st hr

q15min

assessment 2nd hr

q30min

assessment 1st 24 hrs

q4hrs

assessment after 24 hrs

q8hrs

immunizations

rubella vaccine and TDAP to mother after birth, RhoGAM within 72 hours (Rh - mother, Rh + child, first dose at 28 wks pregnant)

considerable diuresis occurs after birth

up to 3000 mL which begins within 12 hours of birth and can last for several days a full bladder can displace uterus urinary retention can lead to UTI and uterine atony

pt who reports calf pain and has nonpitting edema from R knee to foot should be prepared for a

venous duplex US (ultrasound) - noninvasive and visualizes veins and flow patterns

VS normals postpartum

temp - *<100.4* pulse - 40-60 bpm (puerpal *bradycardia*) resp - 16-24 breaths/min BP - WNL pain - manage so it is between 0-2 on 10 pt scale