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NURSING 306 OB Exam 2 Study Guide OB Hartman GOLD, A+ Guide - West Coast University.
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Stuvia.com - The Marketplace to Buy and Sell your Study MaterialOB EXAM 2 FINAL STUDY GUIDE
* Test 2
* Final
OB Exam 2 Study Guide
1. Normal postpartum changes, Assessments & Discharge Teaching Postpartum period: 6 week period after childbirth
https://www.youtube.com/watch?v=PJvK7Xbs0DQ
The Reproductive System
Uterus: The uterus needs to be contracted to prevent hemorrhaging
➢ Women who are in a healthy state and had a low risk pregnancy
have a lower risk for complications
➢ Women are at risk for infection and hemorrhage
➔ Involution: uterus returns to pre-pregnant size, shape and
location
➔ Afterpains: moderate to severe cramp-like pains RT/ uterus
contracting &/or the release of oxytocin from the infant suckling
Nursing Actions:
1. Assess the uterus for location, position and tone of the fundus
(inform, explain, and instruct pt to void)
○ An over distended bladder may cause uterine atony
(decreased uterine muscle tone that may lead to
postpartum hemorrhage)/displacement, therefore
voiding gives you an accurate assessment
Rationale: An over distended bladder can result in uterine displacement
and atony. Encouraging the woman to void prior to uterine assessment will
allow for an accurate assessment of uterine placement and tone.
○ Hemorrhage: Primary (early) first 24 hours after birth
& Secondary (late) 6-14 days following birth.
○ Place pt in supine position
2. Locate the fundus with the other hand using gentle downward
pressure
3. Determine the tone of the fundus:
○ Firm = contracted
○ Soft = boggy: indicates that the uterus is not
Immediately after delivery the fundus is right at the umbilicus, feels like fist contracting and places the woman at risk for
- Every PP day fundus drops 1cm excessive blood loss. INTERVENTION: massage the
- Day 9-10: cannot feel fundus at all uterus to stimulate contraction/ give Oxytocin to
stimulate contraction
- Should be firm 4. Measure the distance between the fundus and umbilicus with
- If it’s boggy -> at risk for PP hemorrhage your fingers (each finger breadth is 1 cm)
1. Massage the fundus immediately & reassess in 30 min 5. Determine the position of the uterus
2. If massage is not helping, give oxytocin Rationale: A uterus that is shifted to the side may indicate a distended bladder.
3. Should be midline A distended bladder interferes with uterine contractibility, which places the
4. If boggy & deviated it means the bladder is full-> always woman at risk for uterine atony and increases her risk of hemorrhage.
massage, if not resolved ask pt to void & reevaluate
5. Assess for clots Expected assessment finding after birth of the placenta:
After birth: uterine fundus is midline between the umbilicus and symphysis
The uterus on the average descends 1 centimeter per day. pubis and is firm at midline
Within 12 hours: level of the umbilicus or 1cm above the umbilicus/ midline
The first nursing action for a boggy uterus is to massage the fundus. 24hrs after: 1cm below the umbilicus / firm and midline
Note: the uterus descends 1cm per day/ by day10 it descends into the pelvis
Oxytocin is commonly used to control postpartum bleeding related to and is not palpable
uterine atony.
★ Boggy Uterus: a sign that the uterus is not contracting
Oxytocin, the hormone of labor, also stimulates the uterus to contract in ○ At risk of excessive blood loss/hemorrhage is ^
the postpartum period in order to reduce blood loss at the placental site. ○ Immediate action is to massage the fundus with the
palm of your hand in a circular motion until firm and
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And oxytocin is the same hormone that regulates the milk ejection reevaluate within 30 min
reflex. Whenever a mother breastfeeds, therefore, oxytocin stimulates ○ If the uterus does not respond to massage, follow the
her uterus to contract. In essence, therefore, breastfeeding naturally standing order for oxytocin and notify the HCP
benefits the mother by contracting the uterus and preventing excessive
bleeding. Endometrium: the mucous membrane that lines the uterus
● Lochia: bloody discharge from the uterus that contains sloughed
The uterine fundus is palpated by placing one hand on the base of the off necrotic tissue
uterus immediately above the symphysis pubis and the other hand at the ● Primary complication is Metritis: infection of the endometrial
level of the umbilicus. The nurse presses inward and downward with the tissue
hand positioned on the umbilicus until the fundus is located. It should
feel like a firm, globular mass located at or slightly above the umbilicus Metritis: pg. 364. Early ambulation, 3,000mL/day fluid intake, high
during the first hour after birth. The uterus should never be palpated vitamin C and ^ protein, proper hand washing techniques, proper
without supporting the lower uterine segment. Failure to do so may pericare (wipe front to back)
result in uterine inversion and hemorrhage. Primary risk factor: cesarean birth
Assess for clots:
It is common for lochia to contain small clots: due to the pooling of
lochia in the lower uterine segment/ note in pt chart
LARGE CLOTS: should be weighed and finding reported to physician or
midwife (Large clots can interfere with uterine contractions)
Ex. 10grams = 10mL of blood loss
Excessive bleeding:
Note: Continued heavy bleeding with good fundal tone may indicate the
presence of a genitourinary tract laceration or hematoma of the vulva or
vagina
LOCHIA
★ Lochia Rubra (1-3 days)
○ Moderate to scant amount
○ ^ Flow with standing/breastfeeding
○ Bloody with Small Clots Normal
○ Bright red
★ Lochia Serosa (4-10 days)
○ Pinkish to Brownish
○ Scant
○ ^ During physical activity
★ Lochia Alba (Day 10)
○ Yellow to White
○ Scant
Lochia is assessed as scant, light, moderate, or heavy:
Scant is less than 1 inch on the pad.
Light is less than 4 inches on the pad.
Moderate is less than 6 inches on the pad.
Heavy is when the pad is saturated within 1 hour
Excessive lochia: saturating more than one pad in an hour indicates possible
postpartum hemorrhage
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BUBBLEHE (POSTPARTUM ASSESSMENT)
B- Breasts
U- Uterus
B- Bladder
B- Bowels and rectum
L- Lochia
E- Extremities
H- Homan’s sign (dorsiflex foot) dx of thrombosis in the deep vein/ assess for
pain (extended legs, flexed knees followed by dorsiflexion of the foot)
E- Emotional status
Homans' sign is often used in the assessment for deep venous thrombosis
(DVT) in the leg. To assess for Homans' sign, the patient's legs should be
extended and relaxed with the knees flexed. The examiner grasps the foot
and sharply dorsiflexes it. No pain or discomfort should be present. The ★ COMPLICATIONS
other leg is assessed in the same manner. If calf pain is elicited, a positive ○ Infection (prevent infection by changing the peripad)
Homans' sign is present. The pain occurs from inflammation of the blood ■ Foul Odor
vessel and is believed to be associated with the presence of a thrombosis. ■ Placental fragments
Pain on dorsiflexion is indicative of DVT in approximately 50% of ○ Hemorrhage
patients. A negative Homans' sign does not rule out DVT. ■ Large clots
■ Heavy amounts
■ Saturated pad within 15 min or less
Postpartum women should be advised to perform three actions to ■ Bright Red Bleeding
prevent infections:
(1) Change their peripads at each toileting because blood is an excellent
medium for bacterial growth Vagina and Peritoneum: lay patient in side lying position, assess for
(2) Spray the perineum, from front to back, with clear water to cleanse any lacerations in buttocks as well as hemorrhoids
the area - REEDA
(3) Wipe the perineum after toileting from front to back to prevent the ❏ Redness
rectal flora from contaminating sterile sites. ❏ Edema (mild edema is expected)
❏ Ecchymosis (minor ecchymosis is expected)
❏ Discharge
❏ Approximation – of the edges of episiotomy & laceration
(a bright red trickle of blood from the episiotomy site in
the early postpartum period is a NORMAL finding)
Mild to moderate pain is expected
> Interventions:
● Encourage ice packs for first 24 hours: vasoconstriction/ reduce
edema
● Warm packs and sitz baths after 24 hours: promote circulation,
healing and comfort
● Change pads frequently, wash hands, rinse perineum after
elimination reduce risk of infection (wear pad snuggly to prevent
rubbing)
● Encourage woman to lie on her side to decrease pressure
● Administer analgesia: Ibuprofen for pain and discomfort
● Tighten gluteal muscle as sitting down/ relax after sitting
● Clean the perineal area from front to back (urethra to anus)
● Sparingly use antiseptic topical agent / cream or spray
Breasts:
● Primary Breast Engorgement: due to an increase in the
vascular & lymphatic systems -precedes after the initiation of
production of milk (Woman may feel a throbbing pain in the
breast)
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Occurs 2-3 days PP/ Subsides within 24-48 hours
○
S/S:
○
■ Breast become:
● Larger
● Firm
● Warm
● Tender
● Throbbing pain
Primary engorgement subsides within 24-48 hours
The best way to prevent engorgement is to breastfeed the baby every
2-3 hours
● Subsequent Breast Engorgement: RT/ distention of the milk
glands > should be relieved with baby suckling
○ Complication = MASTITIS (infection of the breast:
may be due to bacterial entry through cracks in the
nipples, and is associated with milk stasis, stress
and fatigue/ IMPROPER INFANT LATCH) pg316&365
○ Typically occurs 3-4 weeks post birth
■ Fever, Chills & Flu-like symptoms
■ Unilateral breast pain
■ Malaise
■ Redness, Tenderness in infected area
Colostrum:
A clear, yellowish fluid precedes (before) milk production. It is higher in
protein and lower in carbohydrates than breast milk. It contains
immunoglobulins G and A that provide protection for the newborn during the
early weeks of life.
Assess for: engorgement, signs of irritation and nipple tissue breakdown &
assess for plugged milk ducts (pg316)
Women may have an elevated temperature:
● TX: Breastfeeding women vs. non-breastfeeding women
○ Frequent feedings preventing milk stasis & emptying of
the breasts
○ Apply warm compresses to the breasts and massage
them prior to breastfeeding
Which of the following nursing actions are important in the care of a ○ Pump the remaining milk after breastfeeding
postpartum woman who is at risk for orthostatic hypotension? ○ Apply ice packs after breastfeeding
(Select all that apply.) ○ Take analgesics as breastfeeding so it does not affect
a. Have patient remain in bed for the first 4 hours post birth. the baby
b. Instruct patient to slowly rise to a standing position. ○ Wear a supportive bra
c. Open an ammonia ampule and have the patient smell the ammonia prior to ■ If NOT Breastfeeding include all but DO NOT
getting out of bed. pump or stimulate breasts > COLD measures
d. Explain to the patient the cause and incidence of orthostatic (ice packs to breasts)
hypotension.
Normal Platelet count: 150,000-400,000/mm3 The Cardiovascular System
A client with critically low platelet count can indicate disseminated CV System: Hypervolemic during L&D
intravascular coagulation (DIC) ➢ 200mL-500mL / 500cc of blood loss during delivery is normal
Cardiac output returns to pre-pregnant levels within 48hrs.
➢ ORTHOSTATIC HYPOTENSION (due to decreased vascular
resistance in the pelvis due to a sudden drop in blood pressure
when the woman stands) is common = FALL RISK / assisted
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