Intrapartum/postpartum postpartum questions content start on slide 42

Disadvantages of Vertical Lower Uterine Incision

Requires repeat cesarean due to higher risk of uterine rupture

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?

Report

Postpartum nutrition

Nonnursing mother should reduce caloric intake by 300 kcal and return to prepregnancy levels of nutrients. Nursing mother should increase caloric intake by 200 kcal over pregnancy requirements of an additional 300 kcal (total 500 kcal increase over prepregnancy status). Teach client to take iron supplements for 4 to 6 weeks after delivery to prevent anemia

. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/ minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

Second stage •Cervix completely dilated •Contractions strong •Intense rectal pressure •FHR assessed every 15 minutes in low risk women, every 5 minutes in high risk situations •Blood pressure every 30 minutes or more often if warranted

Nurse remains with the patient •Provide support , reassurance, clear direction •Cool cloths •Encourage rest between contractions •Assist into pushing position •Sips of fluids or ice chips •Maintain privacy

A maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order?

Obtain equipment for a manual pelvic examination

A nurse is reviewing the physician's orders for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to 36 weeks. Which physician's order should the nurse question?

Perform a vaginal exam every shift.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Place patient in trendelenburg

Factors associated with premature rupture of membranes (PROM) or preterm PROM (PPROM)

Placenta previa •Abruptio placentae •Trauma •Incompetent cervix •Bleeding during pregnancy •Maternal genital tract anomalies

3rd and fourth stage of labor •Place newborn skin to skin on mom's chest to promote bonding. •Dry newborns and keep them covered with warmed blankets •Maintain respirations •Apgar score •Physical assessment •Newborn identification/Security Measures

Recovery period •Monitor maternal blood pressure every 5 to 15 minutes. •Monitor temperature. •Inspect bloody vaginal discharge. •Assess fundus. •Heated blanket •Provide food/fluids •Encourage rest Recovery period •Bladder palpation •Assess for distention. •Promote urinary elimination. •Warm towel across the lower abdomen •Warm water over perineum or over mother's hand •Catheterization if necessary •Inspect perineum for edema and hematoma.

Epidural: Disadvantages

Maternal hypotension-most common complication •May slow labor progress and pushing •Delay in return of bladder sensation requiring catheterization •Soreness at the insertion site •Elevation of maternal temperature

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

. Variable decelerations

A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is:

1 cm above the ischial spine

Thenurseisprovidingpostpartuminstructionstoa client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

1. "I should wear a bra that provides support." 2. "Drinkingalcoholcanaffectmymilksupply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse deter- mines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility

Thenurseispreparingalistofself-careinstructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore.

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

2. "I have the hospital phone number if I have any questions 3. "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." 4. "My mother is coming to help for a month so I will be fine." 5. "I know if I get fever or chills or change in lochia to call the physician."

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous throm- bosis. Which sign should the nurse note if superfi- cial venous thrombosis were present?

3. Enlarged, hardened veins

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

2. Fetal heart rate of 180 beats/minuTe

Thepostpartumnurseisprovidinginstructionstoa client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

A nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply.

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

A nurse in the labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following assessment findings would alert the nurse to a compromise?

4. Persistent nonreassuring fetal heart rate.

A nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?

A multiparous client who delivered a large fetus after oxytocin (Pitocin) induction

Nursing interventions for preterm labor

Administer Tocolytic medication •Suppresses uterine contractions •If delivery is imminent, Betamethasone(2 IM doses) or Dexamethasone(4 IM doses) between 24 and 34 weeks to stimulate fetal lung development. •Progesterone therapy shown to be effective in reducing incidence of preterm births in high risk populations.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late decel- eration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask

Aclient in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embo- lism. Which should be the initial nursing action

Administer oxygen, 8 to 10 L/minute, by face mask.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action

Administer oxygen, 8 to 10 L/minute, via face

1st stage Latent Phase Vitals •BP, pulse, respirations, and pain every hour •Temperature every 4 hours unless membranes are ruptured then its hourly •Uterine contractions every 30 minutes •Active Phase Vitals •BP, pulse, respirations, and pain every hour •Uterine contractions every 15-30 minutes •Transition Phase Vitals •BP, pulse, respirations, and pain every 30 minutes •Contractions palpated at least every 15 min.

Ambulate as tolerated •Change position frequently, with pillow support •Side-lying position-support all body parts •Adjust room temp and offer socks or slippers •Offer oral care •Place damp cloth to forehead or neck Replace chux frequently •Replace soiled linen/gown promptly •Encourage voiding every 1 to 2 hours •Offer to stay with the woman while partner eats or takes a break •Administer pain med as prn

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/minute

Monitor uterine status

Assess every 15 minutes for first hour after delivery, then 30 minutes x2, then hourly for x2, then every 4 hours x2 and then every 8 hours until discharged. •Monitor for complications •Medicate to promote contractions, decrease bleeding (ex. Pitocin and Methergine)

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate.

Risks with vacuum extraction

Assessment includes looking for: •Caput succedaneum •Cephalhematomas •Intracerebral hemorrhages •Retinal and subconjunctival hemorrhages •Bruising •Jaundice •Maternal risks same as forceps

Management/Interventions of Placenta Previa

Bed rest with bathroom privileges while not bleeding •NO vaginal exams/NO internal monitoring •Monitor blood loss, pain, uterine contractility •Monitor maternal vital signs •Evaluate FHR with EFM If preterm, consider Tocolytics •Laboratory evaluation-Hemoglobin/hematocrit-Rh factor DIC studies, Urinalysis •IV fluid (lactated Ringer's solution) •Two units of crossmatched blood available •Psychological Support

Second Stage of Labor

Begins with complete dilatation (10 cm) •Ends with birth of the baby •Urge to push (feels like needing to have a bowel movement) •Cardinal movements •Descent, flexion, internal rotation •Extension, restitution, external rotation, expulsion

Signs of bladder distentioN

Boggy uterus ◦Palpable uterus ◦Palpable bladder Catheterize if not voided within 8 hours of delivery or after urinary catheter removal.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Ch an ges in vital sign s

Over distention of the Bladder can lead to postpartum hemorrhage & UTI

Client needs to urinate & empty the bladder before A fundal assessment is done

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemor- rhoids. What is the priority nursing consideration for this client?

Clients pain level

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

Contact the health care provider (HCP) and inform the HCP of this finding.

Pudendal Block •Administered by a transvaginal method, intercepts signals to the pudendal nerve •Relieves pain of perineal distention and typically relieves pain in the lower vagina, vulva, and perineum. advantages: Maternal vital signs unaffected •May be used to decrease discomfort of forceps or vacuum-assisted birth

Disadvantages: Possible broad ligament hematoma •Perforation of the rectum •Trauma to the sciatic nerve •Decreased urge to push

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's con- tractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An inter- nal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue oxytocin

The nurse is caring for a client in labor and is mon- itoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the elec- tronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well- being

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Encourage the client to increase fluid intake.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake

Which assessment following an amniotomy should be conducted first?

Fetal heart pattern

Stages of labor

First stage: onset of labor to complete cervical dilation •Latent phase—labor onset to 3 cm dilation-able to cope-SROM/AROM •Active phase—4 to 7 cm dilation-anxiety increases •Transition—from 8 to 10 cm dilation-significant anxiety

Complete Breech

Flexion at the thighs and Knees. Feet and buttocks present

Frank breech

Flexion at thighes Extension at knees Feet up by head Buttocks present

A nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse monitors for which adverse reactions of the medication. Select all that apply.

Flushing depressed respirations extreme muscle weakness

Footling

Footling single or double.Extension at the thighes or Knees. Foot or feet present

The nurse is assisting a multiparous woman to the bathroom for the first time since delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The patient turns pale and feels weak. The first action of the nurse is to:

Help the patient back to bed and check her fundus.

Retention of placental fragments is biggest reason for

Hemorrhage

The nurse in the postpartum unit is caring for a cli- ent who has just delivered a newborn infant fol- lowing a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to mon- itor the client for which risk associated with pla- centa previa?

Hemorrhage

A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which of the following, if stated by the client, would indicate a need for further instructions?

I should wash my nipples daily with soap and water."

The nurse is completing the discharge instructions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions?

I will need to be checked out by the doctor in one week."

Uterine stimulants:

IV Oxytocin-10-40 units in 1000 NS or Lactated Ringers. Monitor for hypotension/water intoxication (rare)/hypertonic uterine activity •Methergine-0.2mg IM not IV every 4 hrs, maximum 6 doses. Can be switched to .2mg oral. Contraindicated if high blood pressure. Monitor for hypertension Prostaglandin-0.25 mg IM maximum 8 doses. Monitor temp q1-2 hrs for prostaglandin induced fever Contraindicated if cardiovascular, renal, liver disease or asthma. Monitor for fever/chills, headache, n/v diarrhea. •Cytotec-800-1000 micrograms rectally •Prostin E2-20 micrograms every 2 hours. Contraindicated if hypotension, asthma, acute inflammatory disease

Nursing Interventions for Precipitous Labor

Identify client at increased risk •History of precipitous labor/very short labor •Labor augmentation with oxytocin •Frequent monitoring •Assess for accelerated labor progress •Intense contractions with little uterine relaxation between contractions •Rapid fetal descent Side-lying position •Supplemental oxygen, as needed •Continuous EFM •Administer tocolytic as ordered

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F. What is the priority nursing action?

Increase hydration by encouraging oral fluids.

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply

Increased efficiency of contractions Theneedforfrequentfetalheartratemonitor ing to detect the presence of a prolapsed cord

The nurse is assessing a client who is 6 hours post- partum after delivering a full-term healthy new- born. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

Nursing Care for Induction of General Anesthesia

Large bore IV with crystalloid fluids •Prophylactic antacid as ordered •Cimetidine or Bicitra •Preoxygenate for 3 to 5 minutes with 100% O2 •Wedge under R hip to displace uterus off the vena cava •Cricoid pressure as ordered during intubation

Implications

Loss of coping ability •Laceration of cervix, vagina, or perineum •Postpartum uterine atony •Hemorrhage from undetected lacerations or atony •Fetal stress or hypoxia from intense uterine contractions •Fetal cerebral trauma from rapid descent •Fetal pneumothorax from rapid descent •Brachial plexis injury

A nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which intervention as the highest priority?

Monitoring the fetal heart rate

Precipitous Labor lasting < 3 hours that results in a rapid birth. Common causes

Multiparity •Large pelvis •Previous precipitous labor •Small fetus in a favorable position •Strong contractions •Uterine hyperstimulation from excess Pitocin

A nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

My contractions will increase in duration and intensity."

A primiparous client, 48 hours after a vaginal delivery, 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 of the following

Orange juice

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoor- dinated contractions that are erratic in their fre- quency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures

Endometritis: infection of the uterine lining

S&S: foul smelling lochia, sawtooth fever, uterine tenderness, abdominal pain, increased pulse with elevated temp •Treatment: prophylactic cephalosporins or PCN antibiotics prior to or during the C section •Pelvic Cellulitis(Parametritis): infection involving the connective tissue of the broad ligament or pelvic structures, high temps chills, malaise, lethargy, abdominal pain, local and referred rebound tenderness, tachycardia, sub involution of the uterus •Treatment: Broad spectrum antibiotics until C&S results are complete.

Third stage of labor—from birth of infant to delivery of placenta

Signs of placental separation •Globular-shaped uterus •A rise of the fundus in the abdomen •A sudden gush or trickle of blood •Further protrusion of the umbilical cord out of the vagina •Delivery of placenta •Dirty Duncan •Shiny Schultze

An ultrasound is performed on a client at term ges- tation who is experiencing moderate vaginal bleed- ing. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription

Strict monitoring of intake and output

Aclient in labor is transported to the delivery room and prepared for a cesarean delivery. After the cli- ent is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the righ t h ip

Afteraprecipitousdelivery,thenursenotesthatthe new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the new- born infant.

Postpartum psychological adaptations

Taking In phase-1-2 days after delivery-passive, dependent, preoccupied with self. Food and sleep are major needs. Taking hold phase-2-3 days after delivery-more independent, good time to teach. Ready to resume control Letting go phase-strives for independence with parenting skills

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply

The cervix is completely dilated the spontaneous urge to push is initiated from perineal pressure

A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted?

The cervix is dilated completely

The nurse is performing an assessment on a client who has just been told that a pregnancy test is pos- itive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

Fourth Stage Signs and Symptoms

The time from 1-4 hours after birth •Decreased systolic/diastolic BP •Increased pulse pressure •Tachycardia •Uterine fundus firm, midline, below umbilicus •Shaking chills •Hunger/thirst •Hypotonic bladder

Uterine atony •Pitocin, Methergine, Cytotec, Hemabate, interuterine balloon. •Lacerations •Call the physician •Hematoma •Small ones resolve on there own, larger ones may require drainage •Subinvolution •Methergine, Antibiotics, Dilation and curettage to remove fragments of the placenta.

Treatments

A fundus that is above the umbilicus & feels soft and spongy is associated with bleeding.

Uterine atony

A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruption placentae. Which of the following assessment finding would the nurse expect to note if this condition is present?

Uterine tenderness

Interventions for abruptio placentae

Vital signs every 5 to 15 minutes •IV fluids •Labs-CBC, clotting studies (DIC) •Type and cross match •PRBCs/Plasma •Skin color and pulse quality hourly •Measure CVP hourly, as ordered •Intake and output •Measure abdominal girth, increases with bleeding •Fetal status/uterine activity

A bleeding laceration is typically manifested by:

bright red bleeding and a firm uterus

Perineal laceration

fundus firm with vaginal bleeding

Hematoma

fundus firm, no vaginal bleeding seen, deep, severe, unrelieved pain, systemic signs of blood loss

Postpartum bladder changes

oIncreased bladder capacity oSwelling and bruising of tissues around the urethra oDecrease in sensitivity to fluid pressure oDecrease in sensation of bladder filling oAt risk for over distention and incomplete bladder emptying oIncreased chance of infection due to dilated ureters and renal pelvis oUrinary output is greater due to post partum diuresis-2000-3000ml

Postpartum uterine changes

oUterine cells will atrophy oUterine debris in the uterus is discharged through lochia ◦lochia rubra is red (first 2-3 days) ◦lochia serosa is pink (day 3 to day 10) ◦lochia alba is white (continues until about 6 weeks)

Placenta Previa

placenta implanted in lower uterine segment (painless, bright-red bleeding)

Retained placental fragments

placenta needs to be inspected for intactness

Superficial venous thrombosis-

tenderness, local heat and redness, normal or low grade fever, possibly slight elevation in pulse Management-analgesics, rest, warm moist heat, Teds.

Abruptio Placentae (Placental Abruption)

the premature separation of a normally implanted placenta from the uterine wall. •Severe pain, dark red bleeding •Leading cause of perinatal mortality.

Uterine inversion

uterus turns inside out, management-manual repositioning

Nursing InterventionsDuring Spinal Anesthesia

• After the anesthetic agent is injected. Position woman supine with left uterine displacement. •Rolled towel or blanket under right hip •Monitor maternal blood pressure and pulse per protocol or physician's order. If spinal block used during vaginal birth: •Monitor uterine contractions. •Instruct the woman to bear down during a contraction.

Spinal Block (approach when immediate anesthesia needed for an emergency C section)........ Disadvantages

•High incidence of maternal hypotension due to sympathetic blockade •Alterations in FHR •Fetal hypoxia •Maintains uterine tone, inhibiting intrauterine manipulation •May inhibit pushing ability •Spinal headache

Abruptio Placentae: PotientalRisk Factors

•Maternal hypertension •Domestic violence •Abdominal trauma •Presence of fibroids •Uterine over distension •Multiple gestation Alcohol consumption •Cigarette smoking •Cocaine use •Placental anomalies •Previous abruption

A nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes:

•Reposition the client (2) •Stop the oxytocin infusion (1) •Perform a vaginal examination (4) •Check the client's blood pressure (5) •Administer oxygen by face mask at 8 to 10L/min (3) •Administer medication as prescribed to reduce uterine activity (6)

Nursing Interventions DuringEpidural Anesthesia

•Side-lying position •Sitting position •Assess sensorimotor ability every 30 minutes •Assess for bladder distention •Protect lower extremities from injury •Frequent assessment of maternal vital signs until block wears off