Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
36 Cards in this Set
- Front
- Back
|
What labs are needed in the PP assessment?
|
blood type and Rh
rubella hep B Syphillis (RPR) HIV GBS prenatal hgb/hct |
|
|
What are the nursing tasks if the pt is not immune to Rubella
|
Offer vaccine to prevent rubella in subsequent pregnancy
live vaccine so NO pregnancy x 28days informed consent document teaching HOLD if allergic to eggs, neomycin, or immunosuppressed |
|
|
What are the nursing tasks if the mom is Rh Negative and the baby is Rh Positive?
|
give RhoGAM within 72hrs of delivery
Blood product must be checked by 2 nurses IM injection prevents Rh sensitization for Rh- mom having Rh + baby in the future |
|
|
What should be assessed in the 12 point PP check?
|
VS
Breasts Uterus Bowels/Abdomen Bladder Lower - Extremities Homan's Sign Emotional status Rest Nutrition |
|
|
What should you assess about vital signs?`
|
q15minsx1hr then q30mins x1hr
q4hrs first 24hrs PP, then q8hrs until d/c home BP - consider baseline, variations need further assessment P- usually bradycardia RR - 12-20 T - up to 100.4 in the first 24hrs (hydrate if >100.4 - consider infection) Pain (always reassess) |
|
|
What should you assess about the breasts in the 12 point check?
|
size, symmetry, shape
areola and nipple PPD 1&2 usually soft, nontender; may be filling PPD 4 engorgement is possible thus palpate for firmness Lumpy breasts may indicate milk production and sinus filling |
|
|
What should you assess about the uterus in the 12PP check?
|
consistency
location firm (ok, no massage) Firm with massage (expel clots with gentle massage, maintain firmness, bladder) Soft/Boggy (massage but still atonic, notify MD expect oxytocin orders) |
|
|
What should you assess about lochia?
|
amt
color odor less with c/s may have heavy flow when up for the first time in AM due to pooling in the vagina Absent lochia (possible infection) |
|
|
What should you assess about the perineum in 12point PP assessment?
|
Assess episiotomy or laceration
Redness Edema Ecchymosis Drainage Approximation |
|
|
What should you assess about hemorrhoids?
|
Sims position
note size & number If painful, may interfere with amb, infant care, and bowel elimination |
|
|
What should you assess about the abdomen/BS?
|
abdomen should be soft, nontender
Nondistended Active BSx4 quadrant - if in one quadrant = impaction If dressing present, D/I -remove dressing per orders (usually POD 1 or 2) - shower per protocol or physician order |
|
|
What should you assess about voiding?
|
measure 1st 2-3 voids
300mL void, consider + empting recheck fundus after void report s/s UTI |
|
|
What should you assess in the bowels?
|
What is routine for the client
flatus first before ambulation and suppository Usually have BM day 2-3 PP give stool softener, adequate water, fiber |
|
|
What should you assess in the lower extremities?
|
edema (+/-) pitting nonpitting
Varicosities Pulses Homan's Sign (+/-) -observe FIRST sign for redness or warmth or edema - extending leg with knee slightly bent, dorsiflex foot - assess for pain with dorsiflexion |
|
|
What should you assess about rest/sleep 12 point PP check?
|
amt of sleep during night
naps signs of fatigue what is interfering with sleep |
|
|
What should you assess about nutrition with 12 point PP check?
|
type of diet
amt consumed tolerating intake? adequate PO water |
|
|
What should you assess about the emotional status in the 12 PP check?
|
mood
energy eye contact posture unusual behaviors crying comfort |
|
|
What are some normal attachment interactions with the infant?
|
maternal touch
verbal interaction response to infant cues fathers interactions sibling involvement identify strengths interventions to promote attachment |
|
|
What are some comfort nursing intervention?
|
ice pack (ice diaper prevents edema)
pericare topical meds sitting sitz bath (for lacerations) analgesia (tylenol, NSAIDS, Narcotics, Self med kits) |
|
|
What should you educate the pt about for pericare?
|
water (or water with cleaning solution)
pat dry change pad after every void or defecation (better for counting pads) Check for bleeding in butt (prevent hemorrhage) |
|
|
What are the nursing interventions with rest?
|
rest with the infant
feed side-lying "no visitors" sign or block calls At home: -accept help -Postpone housework -let family help with kids -no major house hold projects |
|
|
What are the nursing interventions for nutrition?
|
2500ml water/day
min 1800 cals/day balanced diet |
|
|
What are the education points of exercise?
|
no exercise program until 4-6weeks
Kegels Abdominal toning |
|
|
What are the educational teaching for emotional well-being?
|
s/s baby blues vs depression
adequate rest relates to emotional well-being Realistic expectations |
|
|
What should you teach the the patient about the reportable S/S PP?
|
fever
breasts: red,swollen, pain unrelieved with meds Persistent abdominal pain feeling of pelvic fullness or pelvic pressure persistent peri-pain frequency, urgency, pain with urination change in amt, color of lochia, + clots, odor localized tenderness, redness,warmth, edema in LE Incision with redness swelling, drainage or separation |
|
|
What should you educate the patient about r/t infant care?
|
demo infant care then have parent assist and gradually take over
simple to complex tasks + reinforcement be tactful with suggestions |
|
|
What should you educate the patient about r/t family care?
|
prolonged contact with infant helps promote attachment
teach that mom-baby are #1 priority for first 4-6 weeks relax schedule enlist help |
|
|
What are the nursing interventions for c/s pt r/t pain management?
|
PCA (single dose opioid) PCEpi
assess S/E of meds |
|
|
What are the nursing interventions for c/s pt r/t RR status?
|
monitor the rate and insufficiency (ISE)
|
|
|
What are the nursing intervention for c/s pt r/t mobility?
|
TC&DB
Early, frequent ambulation TED or SCD until ambulation (or D/C home) Abdominal distention incision care |
|
|
What should you educate a c/s pt r/t psychological well being?
|
disappointed if unanticipated
more focus on self due to comfort watch attachment with infant- provide assistance with infant care and feeding |
|
|
What are some nursing interventions with BF?
|
medicate 30min prior to help with after pains and pain
void and stools = adequate intake |
|
|
What are some nursing interventions with bottle feeding?
|
snug bra on 24h day until breasts are soft
ice packs for vasoconstriction pain management No warm compress, pumping, or massage Feed infant q3-4hrs 1-2oz burp q10min or 15mL |
|
|
How do you prepare formula?
|
mix powder formula according to package instruction - do not over dilute
Once bottle is offered to inf, use within one hr: do not refeed d/t risk of bacterial growth ok to open at room temp x4hr |
|
|
What is important to understand for early discharge?
|
the education NEEDS to be the same!!
|
|
|
What is important to know about follow up options?
|
Phone nurse (warm-line)
Home visit (2nd day home) Office visit 4-6 weeks PP |
