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NRSG 3302 Module 2 Questions And Answers Latest Update 2024/2025
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NRSG 3302 Module 2 Questions And Answers Latest Update 2024/2025
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NRSG 3302 Module 2 Questions AndAnswers Latest Update 2024/2025
post partum assessment
confirm stability then move to history
- determine physiologic needs (vital signs, assessment, comfort)
- review AP and intrapartum history
- need for immunizations
- determine educational needs
- consider religious and cultural factors
- assess for language barriers
- intimate partner violence screening
HBIG
hepatitis b immunoglobulin
- made from blood and contains hep b antibodies
- given to newborn if mother is hep b +
Rh+ baby and Rh- mom
rhogam immunoglobulin given to mom within 72 hours after delivery
postpartum temperature
should be less than 100.4 degrees farenheit
- elevated temp in first 24 hours may be related to dehydration
- if temp is greater than 100.4 on two occasions 6 hours apart assume infection
- postpartum chills and shivers common
postpartum pulse
slight bradycardia could occur (<60)
- tachycardia may be a sign of infection
postpartum BP
,normal range
- elevated BP is not normal
- risk for orthostatic hypotension
orthostatic hypotension
drop in blood pressure when moving from supine to sitting or standing
- fall risk
postpartum respirations
normal range 12-20
postpartum pain
need to continue to assess in all areas
c section assessment
major abdominal surgery, abdominal distention may cause discomfort, assess for bowel obstruction
- early ambulation, increase PO intake, no carbonation, no straws
- bowel sounds and flatus assessed regularly to ensure GI system is functioning properly
c section incision
asses using REEDA - redness, edema, ecchymosis, discharge, and approximation
postpartum focused assessment
BUBBLEHEB
B - BREAST
- inspect for size, contour, asymmetry, and engorgement
- note any reddened areas, tenderness, engorgement, warmth, febrile
- check nipples for cracks, redness, fissures
- note if nipples are flat, inverted, or erect
- educate women on use of supportive bra for 24 hours
- asses for correct latch-on technique if mom is breastfeeding
U - UTERUS
- assess with women lying flat and have her void
- always support the bottom of the uterus during any assessment of the fundus to prevent uterine
prolapse
- firm vs boggy
- midline vs deviated
, - vagina: any lacerations or hematomas
- afterpains
afterpains
intermittent uterine contractions due to involution
interventions for afterpains
- prone position and place a small pillow under her abdomen
- ambulation
- medicate with a mild analgesic
B - BLADDER
- monitor output/assess for retention
- postpartum diuresis: voids at least 300mL
- void within 4 Hours after birth
- early ambulation
- catheterize if unable to void
- assess for UTI's
B - BOWEL
- anatomy returns to normal position
- relaxin depresses bowl motility
- diminished intraabdominal pressure
- incontinence if sphincter is lacerated
- stool softener
- sitz bath for comfort
- medications for hemorrhoids
L - LOCHIA
- educate mother on stages of lochia
- causation mother that an increase in amount, foul odor or return to rubra lochia is not normal
- change pad frequently
- pericare after each void or during to dilute acidic urine and promote comfort
- weigh the pads to get accurate blood loss volume (1g = 1mL)
E - EPISIOTOMY
- lacerations
- assess using REEDA
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