OB Exam 2- Postpartum 52 Questions with Verified Answers
What can the nurse do to encourage bonding/attachment? How do you know if the parents are
... [Show More] bonding with the infant? - CORRECT ANSWER
Rubin's Theory of Maternal Adjustment - CORRECT ANSWER -Stage 1: Taking in
-First couple days PP
-Focused on herself and her self-care needs (food, sleep, etc)
-More passive and dependent, may have difficulty making decisions.
-May need to discuss labor experiences.
-Stage 2: Taking hold
-Usually lasts from day 4 to day 10 PP.
-Focus shifts towards infant.
-More active, independent, and is better eqipped to make decisions.
-Initiates self-care activities along with caring and self-care.
-Typically responds to instruction about infant care and self-care.
-May still express/feel a lack of confidence in caring for the newborn.
-Stage 3: Letting go
-Begins to redefine her new role.
Begins to see herself as separate from her infant (this may be hard for some women.
-Starts the process of giving up the fantasized image of her child and accept the real one.
-Readjusts to her life's new normal.
Positive outcomes from Rubin's Theory of Maternal Adjustment - CORRECT ANSWER -Intro of childbirth classess taught by nurses
-Increased interaction b/w mother an newborn after delivery
-Increased father anticipation during the labor process
-Less sedation used during the delivery process
-Earlier discharge
Kangaroo care
-Visitation allowed for parents and grandparents in NICUs
Puerperium - CORRECT ANSWER After the birth of the baby until the reproductive organs return to their normal nonpregnant state- can be related to conditions experienced after birth of baby (puerperal infection)
PP Physical Adaptations: Reproductive system- Uterine involution - CORRECT ANSWER -Involution: The uterus contracting back down to its original size and location
-immediate
-when it contracts, it helps close off and reduce the bleeding from the vessels connected to the placenta. If the uterus does not contract, it can increase the mother's risk of PP hemorrhage. Part of the assessment is to make sure the uterine involution part is happening.
-Uterus is about the size and shape of a pear and located in the pelvic cavity (not palpable)
Factor that retard uterine involution - CORRECT ANSWER -Precipitous or prolonged labor- really fast labor or really slow labor.
-Anesthesia- muscle relaxer; can reduce uterine contraction
-Difficult birth- uterus was manipulated excessively.
-Grandmultiparity- had more than one birth; more than 4 or 5 births.
-Full bladder- when the bladder is full, there is not enough room for both the bladder and the uterus; so it shoves the uterus off to the side and it cannot contract as effectively as it should when midline in the pelvic cavity.
-Incomplete expulsion of the placenta/infection- starts inflammatory response in the uterine lining so it cannot contract as effectively as it could.
-Overdistention of the uterus- Anything that made it get excessively large is a risk factor for not letting the uterus get back to normal size. (Ex. more than one baby, large baby, too much amniotic fluid)
PP Physical Adaptations: Reproductive System- Lochia - CORRECT ANSWER -Lochia- vaginal discharge that occurs in the PP following delivery; begins immediately and transitions throughout the PP.
-Lochia rubra- bright red, period-type blood, clots (up to golf ball size, benign), RBCs; First 2-3 days.
-Lochia serosa- Lighter, light pink or brown, more mucus and WBCs, days 3-10.
-Lochia alba- White/clear, more WBCs than RBCs. stops on average about week 3 or 4, but can last up to week 6.
PP Physical Adaptations: Reproductive System- Cervical changes - CORRECT ANSWER -Opening to the uterus, closed before birth.
-Closing in the PP, cervix will never go back to pinpoint opening, it is more like a slit.
-Takes a couple weeks to fully close.
PP Physical Adaptations: Reproductive System- Vaginal changes - CORRECT ANSWER -Initially it could be red, edematous, sore.
-Until the women begins to have periods again, the vaginal mucosa can be thin and dry because of lack of estrogen production.
-Can cause painful sexual intercourse when continued.
PP Physical Adaptations: Reproductive System- Perineal changes - CORRECT ANSWER -Could be unchanged from labor but, many women will have a laceration or episiotomy.
Episiotomy - CORRECT ANSWER -Episiotomy- make an incision with scissors of the perineum in order to help facilitate delivery if it is not large enough.
-Midline- straight down towards the anus; more of a risk ripping down towards the anal sphincter; done more frequently.
-Medial/lateral- off to the side' bleed more, do not heal as well, more painful
Laceration Degrees - CORRECT ANSWER -1st degree- Least severe; most simple cut, extends only through vaginal mucosa.
-2nd degree- includes everything in the first degree; most common type; extends into submucosal tissues of the vagina including the muscle but does not involve rectal sphincter or rectal mucosa.
-3rd degree- partial or complete transection of the anal sphincter muscle.
-4th degree- includes lining of the rectum
PP Physical Adaptations: Reproductive System- Breasts - CORRECT ANSWER -In the first 24 hours, the breasts are producing colostrum.
-2-4 days- milk will come in, large, heavier may feel lumpy b/c of milk ducts.
PP Physical Adaptations: Abdomen - CORRECT ANSWER -In pregnancy, as the woman's uterus gets larger, and the baby gets larger, there is a separation between the rectus muscles of the abdomen.
-Cartilage between them separates and gets larger called Diastasis recti.
-Does not snap back immediately; have PP belly' takes time to come back together and some never have it come back together.
-Lay down, raise head up off the floor and see how many fingers we can place between the two muscles.
-1-2 finger- normal finding
- 3 or more fingers- still have diastasis of the muscles (also is normal)
PP Physical Adaptations: GI - CORRECT ANSWER -In pregnancy, GI motility slows down to help absorb nutrients and water it needs to nourish the baby in her stomach.
-Decreased muscle tone, pain medications, all setting her up for constipation.
-Usually give women stool softeners as a bedside medication PP regimen.
PP Physical Adaptations: GU - CORRECT ANSWER -May be some swelling and bruising of the tissue around the urethra, may be blood tinged urine due to irritation.
-The woman has increased bladder capacity, decreased sensitivity to fluid pressure (decreased sensation of bladder filling).
-PP diaresis
-Uterine subinvolution
PP diaresis - CORRECT ANSWER -PP diaresis- once they are in the PP, there is a lot of urine production associated with issues voiding or knowing that she needs to void; can lead to UTI or urinary problems.
Uterine subinvolution - CORRECT ANSWER -Caused by full bladder; pushes uterus off to the side.
PP Physical Adaptations: PP chill - CORRECT ANSWER -Lots of women shake during PP; sudden release of pressure on the pelvis; adrenaline from delivery; epidural related.
-Only last a couple of hours and goes away on its own.
-Unknown physiological causes.
PP Physical Adaptations: Vital Signs - CORRECT ANSWER -Temp- Rising temp up to 100.4 in the first 24 hours after birth- normal variation; result from exertion and potential dehydration related to labor.
-HR- puerperal bradycardia: working extra hard, cardiac output for fetus and mom (takes a vacay (slows) because it's been working for 9 months); returns to pre-pregnancy baseline within a week.
-High HR is not normal and would warrant further assessment.
-BP- Transient rise in BP but it should not be significant and should return to pre-pregnancy baseline within a few days.
-Resp- There are no significant changes seen with this population.
PP Physical Adaptations: Blood values - CORRECT ANSWER -Only draw labs in a PP patient if there is a specific reason to do so.
-Coags- Pregnancy is considered a hypercoagulable state- during extra coagulation factors are activated and the increase continues throughout some of the PP.
-Continues for a variable amount of time; everyone is different.
-WBCs- There can be an increase in WBCs- up to 25,000-30,000 in the immediate PP. Not pregnant woman- 4-11,000 or 5-12,000.
-Hemoglobin/Hematocrit- Can be expected to change and will likely lower because they are losing blood. Dependent on estimated blood loss during labor (EBL).
Estimated Blood Loss (EBL) - CORRECT ANSWER -Blood loss depends on whether it was vaginal or a c-section.
-Vaginal= initial up to 500 mL- normal limits.
-C-section= initial up to 1000 mL
-Correlation between how much blood loss and the drop of H/H' 3-4
% in hematocrit is associated with approx. 500 mL of blood loss.
PP Psychologic Adaptations: PP blues - CORRECT ANSWER -Least severe
-Mood lability and emotional hypersensitivity that does not consistently affect the woman's ability to function; adjustment reaction with depressed mood.
-Might experience tearfulness, rapid mood shifts, hard to cope, irritable, anxious.
-Very common; up to 85% of mothers experiencing this condition- can begin 2-4 days after birth and lasts only a few hours or even 2 weeks.
-Contributing factors- rapid changes in hormone levels, emotional letdown following labor and childbirth, physical discomfort, anxiety, fatigue.
-Nursing interventions-
-Letting her know that this is a common, normal phenomenon and had to do with physiological changes that alter psychological feelings, assisting with any care she needs, make sure she gets proper nutrition and adequate rest, teaching support members the signs of worsening depression so she can get help.
PP Psychologic Adaptations: PP depression - CORRECT ANSWER -Depression that occurs in the first year PP; occurs in 10-20% of all mothers. We see this most often around the 4th week PP.
-Risk factors- hx of major depression or prior PP depression, bipolar disorder, depression during pregnancy, lack of stable support relationships, and if there are delivery complications or loss of newborn.
-Nursing interventions-
-Conduct depression screenings, treatment includes individual or group psychotherapy and also antidepressants in combination.
PP Psychologic Adaptations: PP psychosis - CORRECT ANSWER -Most severe and concerning; serious mood disorder with a high risk of suicide or infanticide.
-Very rare, .1-.2% of pregnant women.
-S/s present within the first few days of PP
-Risk factors- personal or family hx of PP psychosis or bipolar disorder.
-Nursing interventions- medical emergency, requires immediate hospitalization to ensure safety, put on psychotropic medications (lithium), also receive psychotherapy inpatient.
PP assessment: BUBBLEHEHE- Breasts - CORRECT ANSWER -Mastitis (inflammation of the breast from a pathogen or infection); caused from a plugged milk duct, fissures or cracks in the nipples and then the baby tries to latch (getting pathogens from the mouth into the breast area).
-Assess the patient's breast when she is breastfeeding to make it less awkward for you and the patient.
-If bottle feeding, we do not want to touch the breast and do more of a visual inspection. We do not want to stimulate the breast.
PP assessment: BUBBLEHEHE- Uterus - CORRECT ANSWER -Most important; to make sure the uterine involution is happening is super important to note.
-Assess: consistency (firm or boggy), location (both side-side and up-down)(want it midline)
-Immediately after birth, 2 finger breaths below the umbilicus.
-Next 12 hours- raises a little bit and is usually around the umbilicus.
-From then on- it should decrease at least one finger breath each day.
-Soon the uterus will not be palpable.
-May experience after pains as it is trying to go back to pre-pregnancy.
PP assessment: BUBBLEHEHE- Bowel - CORRECT ANSWER -Constipation is very common in this patient population and hemorrhoids can occurs
-Tears or any other abnormal irritation can cause problems for the mother.
PP assessment: BUBBLEHEHE- Bladder - CORRECT ANSWER -There can be irritation on the urethra due to pushing out the baby; UTIs are more common among this population.
PP assessment: BUBBLEHEHE- Lochia - CORRECT ANSWER -Drainage after giving birth.
-Assess: characteristics and amount; heavy is technically considered too much but anything under is fine.
-If you saturate the pad in an hour or less this is considered heavy and abnormal.
PP assessment: BUBBLEHEHE- Episiotomy - CORRECT ANSWER -Or laceration; covering whatever wound is present.
-Assess REEDA- Redness, Edema, Ecchymosis, Drainage, Approximation.
PP assessment: BUBBLEHEHE- Hemorrhoids - CORRECT ANSWER -Turn her to her side and lift the butt cheek up. Noting whether they are there or not, how many, size, internal or external.
PP assessment: BUBBLEHEHE- Edema - CORRECT ANSWER -There are medical conditions in this population that causes edema (Most common condition is preeclampsia); if it is not generalized or bilateral then it is more abnormal.
PP assessment: BUBBLEHEHE- Homans - CORRECT ANSWER -Screening tool for DBTs; at elevated risk for clots so this screening tool help assess for DBTs
-Not a great assessment tool because it is sort of inaccurate.
-Bend the knew and dorsiflex the foot, we then assess for pain in the calf.
-S/S of DBT- redness, swelling (unilateral), warmness
PP assessment: BUBBLEHEHE- Emotions - CORRECT ANSWER -We need to assess for the manifestation of PP depression or PP psychosis.
-Have to ask direct and straight forward questions.
Rubella Vaccine - CORRECT ANSWER - In pregnancy, we test the mothers for immunity against rubella.
-Usually problematic for fetuses causing congenital birth defects, miscarriages, etc.
-Can be resulted as a titer; the largest consensus for rubella immunity is 1:8 (1:2. 1:4-nonimmune) (1:16, 1:32, 1:64- immune); IU/mL (7 or less nonimmune; 8=9 equivocal; 10 or greater-immune)
-Do not give the mother the vaccine while she is pregnant or looking to become pregnant; give it to her after she has had the baby; educate her to not get pregnant for at least a month.
Discharge Planning - CORRECT ANSWER -Patient will only be in PP for 1-4 days on average.
-Vaginal 1 day
-C-section 3 days
-Discharge starts upon admission; we sort of teach the whole time and prepare them for discharge the whole time.
RhoGAM - CORRECT ANSWER -Used to prevent isoimmunization
-Occurs when a mom is Rh negative and the baby is Rh positive resulting in the mother's body making antibodies which are programmed to attack the Rh-positive blood cells.
-These antibodies can cross the placenta into the baby's bloodstream which can attack the baby's RBCs with the Rh-positive antigen (considered a "non-cell"). More problematic for the second child than the first child.
-If we give passive antibodies to the mom, her body does not have to make them. and they only last a couple months in the mother's body. This way she does not have any Rh-negative antibodies to attack the baby's RBCs. Can be given during pregnancy.
Contraception Plan - CORRECT ANSWER -If the mom wants to be on a contraceptive until she has another baby or not? She may not choose a contraceptive plan.
-Breast feeding is not a reliable form of contraception.
Meds overview - CORRECT ANSWER -Most of the time they are on a pain med plan and go home with a set routine, stool softener may be taken home with them as well.
-Tylenol and ibuprofen
Car seat - CORRECT ANSWER -Rear-facing until 2
-45 degrees
-Snug harness,
-Clip at armpit level
-Don't cross infant neck or abdomen.
- no swaddle blanket before securing
CPR - CORRECT ANSWER -Good idea to have CPR training but not required.
Home health visit - CORRECT ANSWER -May need to help set them up with that.
PP Hemorrhage - CORRECT ANSWER -Definition: Extensive blood loss; More than 500 mL per vaginal delivery and more than 1,000 mL per c-section.
-Early- within the first 24 hours.
-Different causes for early and late hemorrhage.
-More associated with tone and trauma.
-Late- anytime beyond 24 hours.
Causes of Early/Late Hemorrhage - CORRECT ANSWER -Tone (70-80%)- Uterine tone/involution; uterine atony- without tone (boggy), not contracting- early hemorrhage
-Trauma (20%)- cervical or vaginal lacerations; hematoma; uterine rupture- early hemorrhage
-Tissue (10%)- Placenta and it being retained; important that placenta comes out as a whole; if part of the placenta stays inside, it can cause an inflammatory response-late hemorrhage.
-Thrombin (Less than 1%)- Coagulopathy- abnormal bleeding times/ clotting factors' some women have bleeding disorders where they bleed too much.
PP Hemorrhage Clinical Manifestation - CORRECT ANSWER -D/t increased blood volume of pregnancy, typical clinical signs of blood loss may not manifest until as much as 1800-2100 mL blood has been lost.
-Gish with standing up is normal and not considered PP hemorrhage.
-Skin will be cold, pale, clammy
-Urinary output will decrease
-Pulse will be weak, +1
-Patient might get anxious or restless
-In pregnancy, there is a lot more blood volume in order to help support the pregnancy.
-The mother has more to lose in order to manifest these s/s.
-Do not want to wait until the compensatory mechanism.
PP hemorrhage treatment- Uterine atony - CORRECT ANSWER -Uterine massage- internal or external; can make the uterus contract and firm up.
-Emptying the bladder
-Meds- can help/cause uterine contraction
-Oxytocin (IV)- can be given on top of the other meds.
-Methergine (IM)- cannot give it when the patient is hypertensive because it can cause the BP to increase more.
-Hematobate (IM)
-Cytotec- rectal
-Balloon tamponade- catheter that is put up into the uterus and filled with fluid, it puts pressure on uterine in order to stop the bleeding.
-Surgery
-Artery embolization or ligation
-Uterine compression sutures
-Hysterectomy
PP hemorrhage treatment- Lacerations - CORRECT ANSWER -Stitch up the laceration if there are some-surgical repair.
PP Hemorrhage Treatment- Hematoma - CORRECT ANSWER -A collection of blood, but not escaping into external. Trapped under the layers of tissues.
-Bulge, swelling.
-The patient will feel pressure.
-Tender to the touch.
-Bruising will appear- escaped blood.
-Treatment:
-Can ice it initially because it will help with swelling and will vasoconstrict.
-After 24 hours, we will switch to heat. It will open the vessels back up and will help reabsorb some of that blood.
-Large hematoma; too big to treat it non-surgically. Can cauterize the vessels or I&D (Insertion and drainage).
PP Hemorrhage Treatment- Retained Placental Fragments - CORRECT ANSWER -Logical solution is to get out the rest of that placenta.
-May require another trip to the OR.
-Depends on what tissues are retained and how much tissue is retained.
-Placenta acreeta- placenta is imbedding in the uterus itself and has a hard time detaching.
-Do not always know about it ahead of time.
PP Hemorrhage Treatment- Infection - CORRECT ANSWER -Fluids
-Antibiotics
PP Hemorrhage: Nursing Care - CORRECT ANSWER -Assess for potential cause
-Call for help
-Remain calm
-Express uterus
-Facilitate emptying of bladder if needed
-Administer ordered medications
-Place 2nd IV if needed
-Administer PRBCs of needed
-Monitor strict I/O
-Prep for OR if needed
-Anytime someone is bleeding out, it is a medical emergency.
-Time is of the essence.
-Cannot do this by yourself.
-Fastly evolving situation. [Show Less]