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142 Cards in this Set
- Front
- Back
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What elements need addressed during a maternal post partum assessment? |
B - Breasts U- Uterus B- Bowels B- Bladder L- Lochia E- Episiotomy/Laceration/Incision H- Homan's Sign E- Emotional Status |
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When assessing the breast what do you want to look for? |
Assess, size, shape, symmetry, nipple integrity, nipple abnormalities, color, presence of colostrum/milk, pain, etc. |
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When does milk start coming in and by what time should it be fully in? |
On 2nd day it begins and should be fully in by 5th day. |
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What gland releases prolactin and what does it do? |
Anterior pituitary gland --> milk making hormone |
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What hormone is responsible for let down of the milk? |
Hypothalamus secretes oxytocin. |
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Besides the let down of milk what other action does Pitocin have in the body? |
It contracts the uterus to prevent hemorrhage. |
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When initiation of breast feeding begins its important to provide the mother with education regarding the baby's stomach size. What would you teach her? |
1st day - shooter marble (1tsp) 3rd day- ping pong ball 10th day- large chicken egg |
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If a mother is not breast feeding and asks how long it will take for the milk to go away, how would you respond? |
Without stimulation to the breast milk will go away 8-10 days after birth. |
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How many feedings in 24hours should an infant receive? |
8-12 |
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What are some hunger cues of the infant? |
Awakening, crying, rooting, drooling, hand to mouth activity, licking lips, sticking tongue out, agitation, crying (this is a late sign, ideally want to feed before this occurs.) |
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Where should the nipple be within the baby's mouth to prevent nipple damage? |
On the soft palate |
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This is infection of the interstitial tissue of the breast. |
Mastitis |
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When is the most common time to experience mastitis? |
2-4 weeks after birth
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What are some common causes of mastitis? |
Staph, E. Coli, or Strep- Tight bras, underwire |
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Treatment of Mastitis? |
Moist heat or ice packs, breast support, bed rest, fluids, analgesics, ATB therapy, Continuing emptying of breasts by feeding or pumping- first line treatment. |
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If a lump or stasis of the breast occurs what is something you can do during feeding that can help? |
Turn the babies nose towards the lump. |
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Parladel (anti-Parkinson agent) was previously used for what and why is it no longer used? |
It was used to dry up milk, stopped using because milk would come in after medication was stopped |
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What may be the cause of a uterus that is shifted to the right or left of the midline?
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A full bladder. Palpate the bladder if distended have pt void. If unable to void straight cath will need to be ordered. |
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Immediately after labor what height should the uterus be (why), what would it be a few hours afterwards? |
Immediately --> U2-U3( d/t Pitocin bn admin as soon as placenta is passed) A few hours afterwards should be UU (level of umbilicus) |
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How much should the fundus height of the uterus decrease a day? |
One finger width |
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If a HCP says a mother has a 4th degree laceration what does that mean? |
It means that the tear is from the vagina into the rectum ( can cause encoporesis - leakage of stool) |
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How often should vs be obtained? |
VS's Q15min the 1st hour once Q 30min-1 hour (depending on stability) then once Q4H |
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What medications may be administered to help contract the uterus? |
Pitocin (oral form is methergine aka ergot) |
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Pitcocin and ergot have a complication of? |
Increased BP ....monitor BP frequently |
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What type of information needs to be gathered when assessing the lochia? |
Color, Amount, Presence of clots |
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What colors should be expected when assessing lochia? |
Rubra (red) 1-2 days Serosa (pink) until 7 days Alba (white/cottage cheese) 10 days- 2 weeks |
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What amount of lochia is a red flag, and what amount indicates hemorrhage? |
Red flag is 1 pad an hour Hemorrhage is 1 pad q 15 minuets |
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What should you do if the pt. states they have been passing clots? |
Assess- see if there is tissue present in the clots, clots should be no more than 1 inch |
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What is the best position to have the mother lay to assess the perineum? |
Side laying with upper leg raised |
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How would you assess for a DVT? |
Bilateral pedal pulses, compare appearance of lower extremities, feel for warmth, look for swelling, redness, ask if in pain. |
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If you notice that a mother is not bonding like they should with the infant what should be your next action? |
Look in chart to see if there is anything in it that may need addressed. (psych meds, mental conditions, etc...) |
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What are the three phases of mother-infant bonding? |
letting- in taking- hold letting- go |
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What/when is the taking in phase? |
Mother is dependent on others for her needs, focuses on getting own needs met. 24-48 hours |
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What is the taking hold phase? |
Less focus on physical discomforts of self. Increased confidence of infant care. |
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What is the letting go phase? |
Its the realization that the family has changed. Moms may be totally disappointed in the way there birthing plan unraveled. |
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What are the common pain medications given? (PO, IV, TOPICAL) |
PO- Percocet Lortab Motrin 800mg
IV- Torodol Narcotics
Topical- Dermaplast, and tucks-which hazel |
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When there is break through pain after being admin torodol it is common to give a po analgesic, except? why? |
Motrin, they are both NSAID |
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What are some other non=pharmacological means for pain reduction? |
Ambulation, relaxation, cold pack, moist heat |
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D/c teaching for peri care? |
Change pad, clean lacerations/hemorrhoids, pat dry with every visit to bathroom.
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How long should you refrain from sexual intercourse? |
6 weeks until HCP assess the pt and advices other wise. |
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Why may the first sexual intercourse bee uncomfortable? |
Vaginal Dryness |
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Siblings tend to regress esp. if they are what ages? |
18months - 3 years |
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What are some ways parents could handle child regression? |
Spend alone time with the sibling, give the sibling a gift from the newborn |
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Causes of PPH (post partum hemorrhage)? |
Uterine atony - hydroamnios Laceration of vagina Hematoma - cx, perineum, or libia Retained placenta Full bladder |
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S/S of PPH(post partum hemorrhage)? |
Boggy uterus, large gush or slow trickle, ooze or dribble, tachycardia, severe unrelieved peritoneal pain. |
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Interventions for PPH (Post partum hemorrhage)?
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- determine cause, aggressive assessment, SBAR vital -Pitocin IV, Ergot IM - Teach will cause cramping -SEVERE- lower HOB supine position, foley (monitor for blood flow to kidneys, if there is not there will be no UOP), Establish IV, Blood expanders or administration, surgery |
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This is a condition where all of the clotting factors are used up, clotting in microcirculation which can cause tissue death? |
DIC (Disseminated Intravascular Coagulation) |
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R/f for DIC? |
Fetal demise Infection/sepsis PIH-(Preeclampsia) Abruptio placentae or Previa |
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s/s of DIC? |
Bleeding from unusual places ( orfices- nose, mouth, ears, rectum, may be present in urine, seeping out of incision, IV sites, Injection sites, and bruising (ex. after checking BP) |
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Tx for DIC |
Heparin - prevents further clot formation |
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S.S of pelvic hematoma? |
Unrelieved perineum pain*, swelling, bruising, will feel hard when palpated, can be internal and not visible. |
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Tx for pelvic hematoma? |
Ice pack to perineum, pain medication, Most resorb with time, if large may require surgery |
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Since it is common to have an increased WBC count during and after pregnancy, how would you determine if pt has s/s of infection when focusing on the WBC count? |
It should be trending, it should be lowering every time the lab is drawn if it is raising or staying the same, may indicate inflammation or infection |
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Why do post partum mothers usually have a low grade fever? |
Dehydration |
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This is infection of the uterine lining |
Endometritis |
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Endometritis is usually caused by?. |
Normal flora of vagina and cervix |
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S/S of Endometritis? |
Temp >100.4 within 36 hours after birth, mother is really sick and looks it |
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Management of Endometritis? |
ATB therapy --> if no improvement in 48 hours notify HCP |
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Endometritis can lead to what other complication? |
Peritonitis (infection of the abdominal cavitiy) |
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Peritonitis can lead to what complication that may require surgery? |
Pelvic abscess-- may have to had I&D and drain(s) |
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Causes for DVT? |
Hypercoagulability, venous stasis, blood vessel injury |
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Tx/ prevention for DVT's? |
Heparin/ Ambulation and increase fluid intake |
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What are the three postpartum psychological d/o's? |
Baby blues, postpartum depression, postpartum depression. |
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What postpartum psychological d/o is normal to experience and occurs after birth up to 2 weeks? |
Baby blues
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What psychological d/o is characterized by depression onset during pregnancy or within 4 weeks after child birth lasting at least 2 weeks? |
Post partum depression |
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Postpartum psychological d/o that is characterized by inability to recognize reality, communicate, and relate to others? |
Post partum pyschosis |
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Which postpartum pshychological d/o is a medical emergency/ why? |
Post partum psychosis possibility of harming self or infant |
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S/S of baby blues? |
Insomnia, irritability, fatigue, tearfulness*, mood instability, anxiety |
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If baby blues last longer than_____ weeks, the HCP should be notified. |
2 |
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S/S of post partum depression? |
Most resemble the baby blues in addition to inability to feel love or pleasure toward infant, and they see infant as demanding-self incompetent at mothering. |
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Tx for post partum depression? |
Psychotherapy (Counseling), Social support, Medications ( SSRIs, TCAs)<--- will take 2-4 weeks to start working. |
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What are some general assessment findings that may indicate a cardiac abnormality in an infant? |
Cyanosis, decreased o2 stat, murmur, feeding issues, poor weight gain. |
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What all does the "PKU" heel stick screen for? |
Phenylketonuria-PKU Maple sugar urine disease Galactosemia Hypothyroidism |
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When is the PKU performed and why? |
48 hours / the PKU, maple sugar urine disease, and galactosemia all require nutritional intake before dx can be made. |
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What is the average WT of a newborn? |
7lbs 8oz |
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What Is the average length of a newborn? |
20 inches |
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What is the average head circumference of a newborn |
13-14 inches |
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What is the normal resp. rate and pattern? |
30-60bpm (check q30mins x 2hours) Irregular and unlabored |
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S/s of resp. distress in a newborn? |
Tachypnea, retractions, cyanosis, nasal flaring, grunting, seesaw/paradoxal resp., asymmetry of chest exspansion |
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What is choanal atresia, s/s, and a possible way to dx it? |
It is a blocked airway from nasal passageway and pharynx.( can be one side or both)
S/s include cyanosis at rest- pink when crying
Dx- inability to pass cath down one or both nares |
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What is the normal PR and BP of a newborn? |
P- 120-160 BP - 60-80/40-50 |
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Cyanosis of the hands and feet? |
Acrocynosis |
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What is the reasoning for applying a beanie to newborns? |
To prevent heat loss - also helps to remold the head. |
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If a mother asks how long it takes for an infants head to go back to normal shape how would you reply? |
24-48 hours |
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What is a collection of fluid under the skin on the head that usually crosses the suture lines? |
Caput succedaneum |
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What is a collection of blood under the skin on the head that does NOT cross the suture line? |
Cephalhematoma |
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What eye characteristics are common in newborns? |
Edematous eyelids, strabismus, and nearsightedness |
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What is strabismus? Why is it common in newborns? When does it usually subside? |
Cross eyed, immature or week eye muscles, 3-4 months |
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What reflexes are common to see in new borns? |
rooting, sucking, gag, swallow, blink, burp, hiccup, sneeze, tonic neck reflex (fencing), grasp, step, and crawl. |
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What are common assessment findings in newborns associated with high hormone levels associated with the birthing process? |
Female and Male genitalia swelling, gynecomastia |
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When may the sucking reflex of an infant be absent? |
Premature infants |
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What is a nursing intervention that should be performed when a infant is receiving nutrition through a OG tube to help develop the sucking reflex? |
Place pacifier in mouth so that they can associate the felling of fullness in the stomach with sucking. |
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What is it called when the testes have not descended? |
Cryptorchidism ( usually descends by 3 months ) |
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Dimples or tuft of hair on a newborn's back are s/o? |
spina bifida occulta |
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What does syndactyly and polydactyly mean? |
Lack of digits / Extra Digits |
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Abduction of leg or foot, uneven fat folds, positive Ortoiani and Barlows tests, and uneven legs are all s/o what in an infant? |
Hip Dysplasia
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If crepitus is palpated over the collar bone it is an indication of? |
Broken clavicle |
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When discussing priorities for adults we say ABC'S, however, with infants it is? |
TABC'S temperature is vital due to large body surface area and low amounts of SQ fat. |
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How often should an infant be feed? |
Breast 1-3h Bottle 2-4h |
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Where are brown fat stores located, why might an infant have deficient amounts? |
On both sides of back (over kidneys), over mediastinum (over heart), and the back of neck (over brainstem)
A newborn may lack brown fat if they are premature. |
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What is proper cord care? |
Keep dry, dap with alcohol to dry out, keep clean, not tub baths until it falls off. |
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A infant should void and pass the meconium in what time frame? |
Before 24 hours |
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If a newborn does not pass meconium in the 1st 24 hours what may you suspect? |
Megacolon |
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How many hours of sleep do infants require? |
16-20 hours.... usually do not sleep over 5 consecutive hours |
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What are the periods of reactivity and when do they occur? |
First period - 30 mins after birth Sleep period -1 - 1 1/2 hours after birth Second period - 4-8hours after birth |
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This is a numerical expression of the newborns well being. |
APGAR score |
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What are the 5 areas that the APGAR, how/ when is it done? |
Respirations, HR, muscle tone, reflex irritability,, and color Each category has a possibility of 2 points, its done at 1 minuet and 5 minuets |
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What is a common trend with wt loss in infants and when should it be regained? |
10% weight loss (@ 7% start looking for feeding abnormalities or wt loss continues after 3 days) Weight should be back to birth weight by day 10 |
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Most common cause of mastitis? |
Not emptying the breast milk |
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What should be told to mothers breast feeding, in regards to bathing? |
Do not use alcohol or soap on breasts will dry out. |
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What are some complications of transition? |
Asphyxia, meconium aspiration, transient tachypnea, hypoglycemia, hypovolemia, and prematurity |
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This is insufficient o2 and excess co2 |
Asphyxia |
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Transient tachypnea goes away in what time period when there is no underlying cause? |
24-48h |
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What should the newborns blood sugar be above? |
50 |
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What are causes of hypovolemia in an infant?
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Abruption of placenta and poor feeding |
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Premature babies have the risk for what system complication? |
Respiratory- its the last system to mature |
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Cause is group b stept., the temp is usually low, tachypnea, tachycardia, nasal flaring, apnea* are all characteristics of? |
Sepsis Neonatorium |
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Tx for Sepsis Neonatorium? |
ATB, Supportive care |
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A neural tube defect characterized by sac-like protrusions of the brain and the membranes that cover it through openings in the skull. These defects are caused by failure of the neural tube to close completely during fetal development. |
Encephalocele |
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The absence of a major portion of the brain, skull, and scalp that occurs during embryonic development. |
Anencephaly |
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A rare neurological condition in which an infant's head is significantly smaller than the heads of other children of the same age and sex. |
Microcephaly |
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What condition is commonly seen with CNS defects in infants, but can also be see alone? |
Hydrocephaly |
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This is the buildup of fluid in the cavities (ventricles) deep within the brain. The excess fluid increases the size of the ventricles and puts pressure on the brain. |
Hydrocephaly |
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What common procedure is performed for hydrocephaly? |
Ventroperitoneal shunt |
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The protective membranes around the spinal cord (meninges) push out through the opening in the vertebrae. Because the spinal cord develops normally, these membranes can be removed by surgery with little or no damage to nerve pathways. |
Meningocele |
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The baby's spinal canal remains open along several vertebrae in the lower or middle back. Because of this opening, both the membranes and the spinal cord protrude at birth, forming a sac on the baby's back. |
Myleomeningocele |
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Is a defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity. |
Diaphragmatic Hernia |
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This is herniation around the umbilical cord. |
Omphalocele |
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This is a defect in the side of the abdomen and the intestines protrude through the defect. |
Gastroschisis |
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This is when an infant is born with the bladder outside of the body. |
Exstrophy of the bladder |
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A congenital condition in which the outer genitals do not have the typical appearance of either sex |
Ambiguous genitalia |
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Intracranial hemorrhage of infants are most commonly caused by? |
Forceps |
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What is a hallmark sign of ICP in an infant? |
High pitched-crying |
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This is an acute lung disease characterized by nasal flaring, cyanosis, intercostal retractions. |
RDS - respiratory disease syndrom |
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Tx for RDS? |
Instillation of surfactant into the trachea. |
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An abnormally high concentration of bilirubin in the blood |
Hyperbilirubinemia |
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Why might failure to pass meconium cause increased levels of bilirubin? |
Because bilirubin is excreted through feces |
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What is bilirubin? |
Breakdown of RBC's |
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a bilirubin-induced brain dysfunction. Bilirubin is a highly neurotoxic substance that may become elevated in the serum, a condition known as hyperbilirubinemia. Hyperbilirubinemia may cause bilirubin to accumulate in the gray matter of the central nervous system, potentially causing irreversible neurological damage |
Kernicterus |
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Why may bottle feeding benefit more so than breast milk with hyperbilirubinemia? |
It takes longer to digest, which pulls more bilirubin into the stool, which will be excreted. |
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Hyperbilirubinemia can be caused when the mother and infant have different blood types and they some how mix... what is this condition called? |
ABO incompatibility |
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This is a condition that causes hyperbilirubinemia, the protiens on the RBC on the mother and infant are opposite. |
Rh incompatibility |
