Nursing – Flashcard

Fundus is boggy when it is not firm, may indicate hemorrhage. Indicative of uterine atony (loss of uterine musculature), if not corrected, results in PP hemorrhage. Massage the boggy fundus to stimulate it to become firm again, or give patient Pitocin, or have the patient breastfeed.

Lay on her side. Tighten buttocks when sitting down to reduce contact of the perineum with the seat and avoid prolonged sitting. Maintain high-fiber diet, high fluids. Begin moderate exercise such as walking.

10-12 lbs initially- infant, placenta, fluid additional 5 lbs d/t PP diuresis.

Placental site takes up to 6-7 weeks to completely heal. Heals by a process of exfoliation. Evaluate lochia- type, amount, and consistency- lochia rubra (2-3 days PP) Lochia serosa (3-10 days PP) Lochia alba (1-2 weeks PP) Trend toward a lighter color and bleeding gets lighter

An indication of incipient or established thrombosis in the leg veins in which slight pain occurs at the back of the knee or calf when, with the knee bent, the ankle is slowly and gently dorsiflexed

Means the patient has a full bladder characteristics: bulging of the lower abdomen, spongy feeling mass between the fundus and pubis, displaced uterus from the midline, usually to the right, increased lochia flow Full bladders may actually cause PP hemorrhage because it prevents the uterus from contracting appropriately Have the patient void

Could mean there's lacerations that still need sutures.

should receive rubella vaccine early PP, administer right after childbirth.

Vaccine to prevent Rh negative mothers from forming antibodies against their Rh positive babies. All Rh negative mothers with Rh positive babies need to get RhoGAM prior to discharge.

Feeding requirement: 140-160 ml/kg/day Caloric requirement: 100-115 kcal/kg/day Observation of breastfeeding technique weight check maternal assessment infant assessment infant feeding history provide breast pump instructions- collection and storage

Engorgement is when the breast is not being emptied enough d/t baby not nursing rigorously enough, separation from baby, not nursing enough. Milk builds up and swelling occurs- breasts become hard, skin is taut and shiny- extremely tender and painful, may fun a low-grade fever and become achy. Alveoli can become atrophied and may decrease milk production. Milk ducts can swell shut- leading to mastitis and plugged duct. Apply moist heat, cold compress, wear a supportive bra , may need antibiotics.

pregnancy can occur before the first menstruation period. Progestin-only hormonal contraceptives are a good idea. No estrogen+ progestin b/c it will decrease milk production. Birth control, implants, and shot of progestin.

Resp rate: 30-60 HR: 120-160 Systolic: 70-100 Diastolic: 50-65 Weight in lbs: 4.5-7 Temp: 97.7-98.9

radiation: body heat transferred to cooler surfaces- walls of a room, walls of an incubator. Convection: warm body surface to cooler air currents- air conditioned room, unwarmed O2 by mask, removal of infant from a incubator for procedures. Evaporation: loss of heat when water converted to vapor- baths. Conduction: loss of heat to a cooler surface by direct skin contact- chilled hands, cool scales, cold exam tables.

accelerated destruction of fetal RBCs. impaired conjugation of bilirubin. increased bili reabsorption from intestines. Bilirubin aids in digestion of fats, green- processed and removed by liver. jaundice will develop when a baby's liver is not efficient enough to remove the bili from the bloodstream- once baby begins to mature and RBCs diminish, jaundice will subside- usually 1-2 weeks after birth

daylight assists in early recognition- press on abd/ forehead/ nose- check icterus. Nursing care: hydration/ promote feedings/ phototherapy/ possible supplement with formula if BF/ parental support- they'll be upset. six factors: increased amounts of bili delivered to liver, defective uptake of bili from plasma, defective conjugation of the bili, defect in bili excretion, inadequate hepatic circulation, increased reabsorption of bili from intestines.