NURSING 306 OB Exam 2 Study Guide OB Hartman GOLD, A+ Guide - West Coast University.
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Nursing course
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Nursing Course
* Test 2
* Final
OB Exam 2 Study Guide
1. Normal postpartum changes, Assessments & Discharge Teaching
Immediately after delivery the fundus is right at the umbilicus, feels like fist
Every PP day fundus drops 1cm
Day 9-10: cannot feel fundus at all
- Should be firm
- If it’s boggy -> ...
* 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:
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
Locate the fundus with the other hand using gentle downward pressure
Determine the tone of the fundus:
○ Firm = contracted
○ Soft = boggy: indicates that the uterus is not contracting and places
the woman at risk for excessive blood loss. INTERVENTION: massage
the uterus to stimulate contraction/ give Oxytocin to stimulate
contraction
Measure the distance between the fundus and umbilicus with your fingers
(each finger breadth is 1 cm)
Determine the position of the uterus
Immediately after delivery the fundus is right at the umbilicus, feels like fist Rationale: A uterus that is shifted to the side may indicate a distended bladder.
Every PP day fundus drops 1cm A distended bladder interferes with uterine contractibility, which places the
Day 9-10: cannot feel fundus at all woman at risk for uterine atony and increases her risk of hemorrhage.
- Should be firm Expected assessment finding after birth of the placenta:
- If it’s boggy -> at risk for PP hemorrhage After birth: uterine fundus is midline between the umbilicus and symphysis
Massage the fundus immediately & reassess in 30 min pubis and is firm at midline
If massage is not helping, give oxytocin Within 12 hours: level of the umbilicus or 1cm above the umbilicus/ midline
Should be midline 24hrs after: 1cm below the umbilicus / firm and midline
If boggy & deviated it means the bladder is full-> always massage, if not Note: the uterus descends 1cm per day/ by day10 it descends into the pelvis
and is not palpable
resolved ask pt to void & reevaluate
Assess for clots
★ Boggy Uterus: a sign that the uterus is not contracting
The uterus on the average descends 1 centimeter per day. ○ At risk of excessive blood loss/hemorrhage is ^
○ Immediate action is to massage the fundus with the palm of your hand in a
circular motion until firm and reevaluate within 30 min
The first nursing action for a boggy uterus is to massage the fundus.
○ If the uterus does not respond to massage, follow the standing order for
oxytocin and notify the HCP
Oxytocin is commonly used to control postpartum bleeding related to
,uterine atony. Endometrium: the mucous membrane that lines the uterus
● Lochia: bloody discharge from the uterus that contains sloughed off
Oxytocin, the hormone of labor, also stimulates the uterus to contract in necrotic tissue
the postpartum period in order to reduce blood loss at the placental site.● Primary complication is Metritis: infection of the endometrial tissue
And oxytocin is the same hormone that regulates the milk ejection
reflex. Whenever a mother breastfeeds, therefore, oxytocin stimulates Metritis: pg. 364. Early ambulation, 3,000mL/day fluid intake, high
her uterus to contract. In essence, therefore, breastfeeding naturally vitamin C and ^ protein, proper hand washing techniques, proper
benefits the mother by contracting the uterus and preventing excessive pericare (wipe front to back)
bleeding. Primary risk factor: cesarean birth
The uterine fundus is palpated by placing one hand on the base of the Assess for clots:
uterus immediately above the symphysis pubis and the other hand at the It is common for lochia to contain small clots: due to the pooling of
level of the umbilicus. The nurse presses inward and downward with the lochia in the lower uterine segment/ note in pt chart
hand positioned on the umbilicus until the fundus is located. It should LARGE CLOTS: should be weighed and finding reported to physician or
feel like a firm, globular mass located at or slightly above the umbilicus midwife (Large clots can interfere with uterine contractions)
during the first hour after birth. The uterus should never be palpated
without supporting the lower uterine segment. Failure to do so may Ex. 10grams = 10mL of blood loss
result in uterine inversion and hemorrhage.
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
★ COMPLICATIONS
○ Infection (prevent infection by changing the peripad)
■ Foul Odor
, ■ Placental fragments
○ Hemorrhage
■ Large clots
■ Heavy amounts
■ Saturated pad within 15 min or less
■ Bright Red Bleeding
Vagina and Peritoneum: lay patient in side lying position, assess for
any lacerations in buttocks as well as hemorrhoids
REEDA
BUBBLEHE (POSTPARTUM ASSESSMENT) ❏ Redness
B- Breasts ❏ Edema (mild edema is expected)
U- Uterus ❏ Ecchymosis (minor ecchymosis is expected)
B- Bladder ❏ Discharge
B- Bowels and rectum ❏ Approximation – of the edges of episiotomy & laceration (a bright red trickle
L- Lochia of blood from the episiotomy site in the early postpartum period is a
E- Extremities NORMAL finding)
H- Homan’s sign (dorsiflex foot) dx of thrombosis in the deep vein/ assess for Mild to moderate pain is expected
pain (extended legs, flexed knees followed by dorsiflexion of the foot)
E- Emotional status
> Interventions:
● Encourage ice packs for first 24 hours: vasoconstriction/ reduce edema
Homans' sign is often used in the assessment for deep venous thrombosis
● Warm packs and sitz baths after 24 hours: promote circulation, healing
(DVT) in the leg. To assess for Homans' sign, the patient's legs should be
and comfort
extended and relaxed with the knees flexed. The examiner grasps the foot
● Change pads frequently, wash hands, rinse perineum after elimination
and sharply dorsiflexes it. No pain or discomfort should be present. The
reduce risk of infection (wear pad snuggly to prevent rubbing)
other leg is assessed in the same manner. If calf pain is elicited, a positive
● Encourage woman to lie on her side to decrease pressure
Homans' sign is present. The pain occurs from inflammation of the blood
● Administer analgesia: Ibuprofen for pain and discomfort
vessel and is believed to be associated with the presence of a thrombosis.
● Tighten gluteal muscle as sitting down/ relax after sitting
Pain on dorsiflexion is indicative of DVT in approximately 50% of
● Clean the perineal area from front to back (urethra to anus)
patients. A negative Homans' sign does not rule out DVT.
● Sparingly use antiseptic topical agent / cream or spray
Postpartum women should be advised to perform three actions to Breasts:
prevent infections: ● Primary Breast Engorgement: due to an increase in the vascular &
(1) Change their peripads at each toileting because blood is an excellent lymphatic systems -precedes after the initiation of production of milk
medium for bacterial growth (Woman may feel a throbbing pain in the breast)
(2) Spray the perineum, from front to back, with clear water to cleanse ○ Occurs 2-3 days PP/ Subsides within 24-48 hours
the area ○ S/S:
(3) Wipe the perineum after toileting from front to back to prevent the ■ Breast become:
rectal flora from contaminating sterile sites. ● 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
○ Pump the remaining milk after breastfeeding
○ Apply ice packs after breastfeeding
○ Take analgesics as breastfeeding so it does not affect the baby
○ Wear a supportive bra
■ If NOT Breastfeeding include all but DO NOT pump or stimulate breasts >
COLD measures (ice packs to breasts)
The Cardiovascular System
CV System: Hypervolemic during L&D
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 ambulation
Use and ammonia ampule if the woman faints
ELEVATED PULSE MAY INDICATE EXCESSIVE BLOOD LOSS, FEVER, OR
INFECTION.
Women are at risk for THROMBOSIS: RT/ increase of circulating clot
factors (coagulation factors and fibrin levels ^)/ clotting factors return to
normal within 2 -3 post partum weeks COMPLICATION: Pul. Emboli /
Thrombus formation
Check CBC, hemoglobin and hematocrit levels, VS, pulses, BP
Assess extremities for venous thrombosis due to increased coagulability
(asses for warmth, calf tenderness, edema, muscle pain @ each shift)
-Encourage early ambulation
- Apply antiembolism hose
Assess pulse and blood pressure:
Every 15 in for the first hour
Which of the following nursing actions are important in the care of a Every 30 min for the second hour
postpartum woman who is at risk for orthostatic hypotension? Every 4hours for the next 22 hours
(Select all that apply.) Every shift after the first 24hours
a. Have patient remain in bed for the first 4 hours post birth. Rationale:
b. Instruct patient to slowly rise to a standing position. Hemodynamic changes occur during labor and delivery and in the
c. Open an ammonia ampule and have the patient smell the ammonia prior topostpartum period. There are rapid changes in blood volume and cardiac
getting out of bed. output. Assessment of pulse and blood pressure is important in
d. Explain to the patient the cause and incidence of orthostatic identification of potential complications such as excessive blood loss,
hypotension. orthostatic hypotension, infection, and gestational
hypertension/preeclampsia. An elevated pulse may indicate excessive
Normal Platelet count: 150,000-400,000/mm3 blood loss, fever, or infection.
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