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After childbirth, the uterus returns to its nonpregnant size and conditon by involution which involves contaction of muscle fibers, catbolic process and regeneration of uterine epithelium
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THe site of placental attachment heals by a process of exfoliation which leaves the endometrium smooth and without scars.
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Involution can be evaluated by measuring the descent of the fundus (about 1 cm/day). By teh 14th day after childbirth, the fundus should no longer be palpable abdominally.
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Afterpains or intermittent uterine contrations cause discomfort for many women particuarly multiparas who breastfeed.
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Vaginal discharge (lochia) progresses from lochia rubra to lochia serosa tol lochia alba in a predictable time frame. Lochia should be assessed for amount type and odor. foul odor suggests endometrial infection.
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it takes 6-10 weeks for the vagina to regain its nonpregnant size and contour.
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Perineal trauma and hemorrhoids cause discomfort and can interfere with activity and bowl elimination.
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As blood from the uterus returns to the central circulation and extracellular fluid moves into the vascular compartment, the cardiac output increases and excess fluid is excreted by diuresis and diaphoresis
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Increasing clotting factors predispose the postpartum woman to clot formation. Early frequent ambulation help prevent thrombi.
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Constipation may occur from decreased food and fluid intake during labor reduced muscle and bowel tone or fear of pain during defecation.
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Increased bladder capacity and decreased sensitivity to fluid pressure may result in urinary retention. Statsis or urine allow time for bacteria to grow and can lead to urinary tract infection
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A distended bladder displaces the uterus and can interfere with uterine contraction and couse excessive bleeding.
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Excersise to strengthen the abdominal muscles good posture and body mechanics may reduce muscloskeletal discomfort.
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As hormone levels decline the skin gradually returns to its nonpregnant state
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Breastfeeding may delay the return of ovulation and menstruation but ovulation may occur befor the first menses all mothers need information about family planning.
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Breastfeeding mothers are more likely to experience dyspareunia as a rsult of vaginal dryness that results from inadequate estrogen
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Lactation may be suppressed by wearing a sports bra and avoiding stimulation of the breasts
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Orthostatic hypotension occurs when the mother goes from a supine to a standing position quickly.
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Tachycardia may be caused by pain excitement hypovolemia fatigue dehydration anemia or infection. Additional assesssments are required to determine if excessive bleeding is the cause
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The postpartum woman should be afebrile but because of dehydration and leukocytosis her temperature may be higher during the first 24 hours after delivery
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THe postceaseran woman requires postoperative as well as postpartum assessment and care. SHe may have problems associated with immobility and discomfort.
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THe quick discharge after childbirth challenges nurses to develop an effective plan for teaching self-care and infants care in a short period.
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Bonding and attachment are gradual processes that begin before childbirth and progress to feelings of love and deep devotion that last throughout life.
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Nurses foster bonding and attachement by providing early unlimited contact between teh parents and infant and by modeling attachement behaviors.
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Maternal touch changes over time as many mothers progress from exploratory fingertipping to enfolding to demostrating a full range of comforting behaviors.
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Verbal behaviors are important indicators of maternal attachment. Nurses often model how to speak to the infant and point out the infants response to verbal stimulation.
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Maternal adjustment to parenthood is gradual process that involves the phases of taking-in, taking-hold and letting-go
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Parents usually progress through four stages of role attainment (anticipatory, formal, informal, and personal) as they learn to structure their parenting behaviors t mesh with the infants needs.
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Many women experience role conflict when they must leave the infant with a caregiver and return to work. Nurses can offer anticipatory guidance that makes the conflict less difficult
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Postpartum blues is a temporary and self-limited period of tearfullness and mood instability. It should not last longer than 2 weeks.
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THe birth of a baby requires reorganization of family structure and renegotioation of family responsibilities. Nurses cAN assist teh fatehr in co-parenting the infant and help the new parents identify family resources.
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Sibilings may be jealous and fear that they will be replaced by the newborn in the affection of the parents. Nurses can help by providing information about how to reduce sibiling rivalry.
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attention to cultural concerns of postpartum families is important
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Method to increase tone of muscle in the vaginal and urinary meatal area.
Kegal exercises
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Part of the uterus above the openings of the fallopian tubes
Fundus
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Longer-term development of affection between the infant and significant other.
Attachement
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Development of an emotional tie to the infant
Bonding
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Conversion of living cellular substance to simpler componds
Catabolism
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Position that facilitiates eye to eye contact between parent and newborn
En face
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Intense fascination between father and newborn
Engrossment
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Movement of the newborn in rhythm with adult speech
Entrainment
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initial touch characteristic between mother and newborn
fingertipping
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Retrogressive changes that return the reproductive organs to their pregnancy states
Involution
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Period from childbirth until return of the reproductive organs to their prepregnancy states
Puerperium
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Acronym that helps assess wound healing (readness, edema, ecchymosis, discharge, approximation)
REEDA
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First phase of maternal adaptation
Taking-in
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Describe postpartum changes in the: UTERINE MUSCLE
Stretched uterine muscle fibers contract and gradually regin their former size and contour
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Describe postpartum changes in the: UTERINE MUSCLE CELLS
Number of uterine muscle cells remains the same but each cell descreases in size through catablolism
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Describe postpartum changes in the: UTERINE LINING
Outer area of endometruim (decidua) is expelled with teh placenta. Remaining decidua separates into two layers. The superficial layer is shed in lochia and the basa layer regenretes new endothelium.
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Discribe the changes in lochia and when the aforementioned changes occur.
Lochia rubra contains blood mucus and bits of decidua it is red in color and has a duration of approximately 3 days
Lochia serosa contains serous exudate erythrocytes leukocytes and cervical mucus it is pinkish in color and its duration is from teh 4th to the 10th day
Lochia alba contains leukocytes deciual cells epithelial cells fat cervical mucus bacteria it is white or colorless its duration varies from teh 11th day until the 3rd or 6th week.
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What is the significance of brady cardia during the early postpartum period
Blood volume and cardiac output increase as blood from teh uteroplacental unit returns to teh central circulation and as excess extracellualar fluid enters the vascular compartment for excretion.
because stroke volume increases pulse decreses
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What makes any pregnant and postpartum woman at risk for venous thrombosis? What factors increase this risk?
Pregnant and postpartum women have highe fibronogen levels which increase the ability to form clots. Factors that lyse clots are decreased, however. Some women have another risk in addition to this baseline risk: those who have varcose veins a history of thrombophlebitis or a cesarean birth.
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Explain how a full bladder at birth can lead to postpartum hemorrhage?
A full bladder interfers witht he ability of the uterus to contract firmly and occlud open vessels at teh placental site. This allows them to bleed freely.
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describe the influence of these hormones on lactation: ESTROGEN/PROGESTERONE
Estrogen and progesterone prepare the breasts for lactation
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describe the influence of these hormones on lactation: PROLACTIN
prolactin initiiates milk production in the alveoli
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describe the influence of these hormones on lactation: OXYTOCIN
Oxytocin causes milk ejection from the alveoli into the lactiferous ducts.
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Discuss postpartum mothers would be appropriate candidates for RHO(D) immune globulin and rubella vaccine
Rho(D)- mother is Rh- newborn is Rh + rubuella if her prenatal rubella antibody screening showed nonimmune
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Describe additional nursing assessments and care for the woman who gave birth by cesarean : Respiratory
observer resp rate and depth (every 30 min to 1 hour if eqidural narcotics were used) monitor for apnea for epidural narcotic administration auscultate breath shound for retained secretions assist the mother to turn cough and deep breath use incentive spirometer
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Describe additional nursing assessments and care for the woman who gave birth by cesarean : ABDOMEN
Assess for return of peristalsis by auscultating bowel sounds observer for abdominal distention observe surgical dressing for intactness and drainage observe incision line after dressing removal for signs of infection (REEDA) palpate fundus gently
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Describe additional nursing assessments and care for the woman who gave birth by cesarean :INTAKE AND OUTPUT
- Monitor intravenous (IV) line for rate of flow and site condition
- observe urine for amount color and clarity
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What teaching should you provide the postpartum woman to prevent constipation?
Increase activity progressively drink adequate fluids (atleast 8 glasses of water daily), add dietery fiber (found in fruits and vegetables and whole-grain cereals bread and pasta) to prevent constipation Prunes are a natural laxative
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List signs and symptoms that the postpartum womanshould report to her physician or nurse midwife
- Fever
- localized area of redness swelling or pain in the breasts that is unrelieved by support or analgesics
- persistent abdominal tenderness or felling of pelvic fullness or pelvic pressure
- presistent perineal pain
- frequency urgency or burning when urinating
- change in lochia character (increased amount return to red color passage of clots or foul odor)
- localized tenderness rednes or warmth of the legs
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Describe the process of bonding and attachment. Note the similarites and diffrences in these processes.
- Bonding describes teh initial rapid attractio felt by parents toward their newborn infant. It is a one way process from parent to infant
- Attachment describes a longer-term two-way process that binds parent and infant
- Attachment is facilitated by positive feedback from the infant and by mutually satisfying experiences.
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Describe progression of maternal touch
maternal touch progression is from fingertipping to palm touch to enfolding the infant and bringing him or her close to the body
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Describe progression of maternal verbal behaviors
Maternal touch progresses from calling the infant (it) to refering to the infant as he or she to using the infants given name
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Describe postpartum blues. What is the best response to them?
- Postpartum blues describe a mild transient depression that affects more than 70% of american women It has an onset within the 1st week after birth and is characterized by fatigue weeping mood instability and anxiety
- the mother may not be able to define why she is upset
- The primary nursing care is to give the empahty and support an let her know that the condition is ususally self-limiting
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How can the nurse help the new father adapt to his role?
- The nurse should involve the fatehr in infant care teaching and decisions
- Fathers may not know what to expect from newborns and benefit from information about growth and development. A review of any prenatal teaching is helpful as well
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How should the nurse respond to the parent who is disappointed in the sex of the newborn
The nurse should help the parent or parents acknowledge their feelings and deal with them to facilitate there attachment with the child
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What nursing measures can help the mother or twins attach to her babies
The nurse should help parents interact with each twin indvidually rather than interacting with them as a package it is essential to point out essential qualities and characteristics of each infant individually
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New parents may not recognize signals from teh infant that he or she has had enough stimulation and now needs to rest. What signals should the nurse teach parents to recognize.
Avoidance cues include looking away splaying the fingers aching the back and fussiness. These are clues that the infant needs some quiet time.
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When checking a womans fundus 24 hours after cesarean birth of her third baby, the nurse findes her fundus at teh level of hare umilicus firm and in the midline. The appropriate nursing action related to this assessment is to:
document the normal assessment
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A women who is 18 hours postpartum says she is having hot flashes and sweats all the time. The appropriate nursing response is to:
Tell her that her body is getting rid of unneeded fluid.
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A woman who is 3 hours postpartum has had difficulty urinating. SHe finally urinates 100ml. The initial nursing action is to:
Assess the height of the fundus
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When teaching the postpartum woman about Peripads the nurse should tell her that:
the pads should be applied and removed in a front-to-back direction
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A young mother is excited about her first baby. Which is the best teaching to help her obtain adequate rest after discharge.
Plan to sleep or rest any time the infant sleeps
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Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum
Warm sitz baths taken four times per day
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To prevent breast engorgment the nurse should teach the non-breastfeeding postpartum woman to:
Wear a well fitting bra or breast binder constantly
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A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurses first action should be to:
Determine whether the bleeding slows to normal or remains large
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To help the postpartum woman avoid constipation the nurse should teach her to:
Drink atleast 2500ml of noncaffeinated fluids daily.
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Which sign or symptom that the new mother should be taught to report
Reappearance of red lochia after it changes to serous
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Twelve hours after birth a mother lies in bed resting. Although she will be discharged in another 12 hours she does not ask about her baby or provide any care. What is the probable reason for her behavior?
She is still in the taking-in phase of maternal adaptation.
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A new fatehr is reluctant to Spoil his newborn when she cries by picking her up. The best nursing response is to:
Tell the father that the baby cries to communicate a need.
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A newborn is rooming in with his teenage mother who is watching TV. The nurse notes that the baby is awake and quiet. The best nursing action is to"
Pick the baby up and point out his alert behaviors to the mother
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The best nursing encourgement for parents to care for their infant is to:
give positive feedback when they provide care.
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the first 6 weeks after the birth of an infant are known as the?
postpartum period or puerperium
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What is involution?
refers to the changes the reproductive organs particularly the uterus undergo after childbirth to return to their nonpregnant size and condition
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What are the three involution processes?
Contraction of muscle fibers
Catabolism (the process of converting cells into simpler compound)
regeneration of uterine epithelium
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when does involution begin?
immediately after delivery of the placenta when uterine mucsle fibers contract firmly around matenal blood vessels at the area where the placenta was attached.
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When does regeneration of the uterine epithelial lining begin?
Soon after childbirth
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What is the decidua?
Endometrium during pregnancy
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how many layers does the decidua seperate into?
- Two layers
- the first layer is superfical and is shed in lochia the basal layer remains to provide the source of new endometrium. regeneration of the endometrium except at the site of placental attachment occurs by 16 days after birth.
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how does the placental site heal?
Exfoliation (scaling off of dead tissue)
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how long does healing of placental site take?
approx 6 weeks
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WHat helps wether involution is progressing normally
the location of the uterine fundus
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By how much does the height of the fundus decrease daily?
- 1 cm/day
- after 14 days the fundus is no longer palpable.
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In who might the fundus be sligtley higher in?
Multiparas or overdistended uterus.
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What is subinvolution
When the process of involution does not occur properly and can cause postpartum hemorrage.
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In who are afterpains more acute for?
Multiparas due to streching of muscle fibers
also multifetal pregnancy
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how much is scant lochia
Less than 2.5 cm (1 inch) stain on the perineal pad
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How much is light lochia
2.5 to 10 cm (1 to 4 inch) stain
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How much is moderate lochia?
10-15 cm (4 to 6 inch) stain
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how much is heavy lochia
saturated perineal pad
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How much is excessive lochia
Saturated peripad in 15 min
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WHy is lochia less in women with c- section
some of the endometrial lining is removed during surgery
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How does the cervix look immediatly after childbirth?
formless, flabby and open wide. Might have small tears or lacerations and often edematous.
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Is there rugae on the vagina after childbirth?
no but are regained by 3-4 weeks it takes 6 -10 weeks for the vagina to complete involution. The vagina does not entirely regain the nulliparous size however
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What is dyspareunia
Discomfort during intercourse
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When does healing of the episiotomy site occur?
in 2-3 weeks and complete healing in 4-6 months
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HOw much blood is lost during labor?
5ooml vaginal
1000ml c-section
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WHy does maternal cardiac output occurs after childbirth?
an increased flow of blood back to the heart when blood from the uteroplacental unit returns to the central circulation
decreases pressure from teh pregnant uterus on the vessels
mobiliztion of excess extracellular fluid into the vascular compartment
cardiac output decreases and returns to prepregnancy levels by 6-12 weeks after childbirth.
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How does the body rid itself of excess plasma volume.
Diuresis (increased excretion of urine)
Diaphoresis ( profuse perspiration)
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When do WBC values return?
6 days after birth
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WHich women are at more risk for thrombophlebitis?
women who have varicose veins
history of thrombophleitis
c-section
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When does the first stool usually occur in postpartum?
2-3 days
normal patterns of bowel elimination usually resume by 8-14 days after birth.
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What may urinary retention and overdistention of the bladder cause?
Increased postpartum bleeding
UTI's
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When does stress incontinece improve?
3 months after birth
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What is diastasis recti?
the longitudinal muscles of the abdomen may separate.
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What are signs of worsening preeclampsia?
Headache
proteiuria
blurred vision
photophobia
abdominal pain
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When might ovulation resume
3 weeks postpartum
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When will non-nursing mothers resume menstration?
6-8 weeks after childbirth.
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Why is oxytocin necesary during lactation?
for milk ejection or letdown
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how much weight is lost during childbirth?
12 lbs
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if the fundus is has intrauterine clots what can it not do?
Contract.
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Absence of lochia like the presence of a foul odor is?
Infection.
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What does REEDA mean?
R- Redness
E- ecchymosis (brusing)
E- edema
D- discharge
A approximation of the wound
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What is REEDA used for?
a reminder that the site of an episiotomy or perineal laceration should be assessed for five signs.
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if the mother can void 300 to 400 ml waht does it mean?
the bladder is usually empty
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What are signs of an empty bladder?
firm fundus in the midline and a nonpalpable bladder.
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Signs of a distended bladder?
location of fundus above baseline level
fundus displaced from midline
Excessive lochia
Bladder discomfort
Bulge of bladder above symphyis
Frequent voiding of less than 150 ml of urine which may indicate urinary retention with overflow
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WHat is a positive Homans sign?
discomfort in the calf with passive dorsiflexion of the foot is a positive Homans sign and may indicate DVT
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What are the three periods of Postpartum?
immediate postpartum period - the first 24 hours
Early postpartum period- the 1st week
late postpartum period - 2nd week throught the 6th week.
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What do ice packs do?
cause vasoconstriction and is most effective if applied soon after birth to prevent edema and numb perineum
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How long do you leave an ice pack on?
until it melts and wait 10 min before putting on another one.
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What should the mother be advised to do before sitting and lowering her weight?
squeeze buttocks together and lower weight slowly
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how much fluid should a postpartum woman drink?
2500ml each day
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signs of paralytic ileus?
abdominal distention
absent or decreased bowel sounds
failure to pass flatus or stools
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WHat should you do if a woman who had an epidural or spinal opiods and has a resp of less than 12 -14 breaths per min do?
notify anesthesiologist immediately
elevate the head of teh bed to faciliate lung expansion
Ask her to breath deeply
admin oxygen and apply a pulse oximeter
follow facility protocol to admin Narcan
observe for recurrence of rep depression because the effect of naloxone (narcan) lasts only approximtley 30 min
Recognize that naloxone reduces the level of pain relief.
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What is bonding?
the inital attraction felt by parents for their infants it is unidirectional from parent to child and is enhanced when parent and infant are permited to touch and interact during the first 30-60 min after birth.
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What is attachement?
THe process by which an enduring bond between a parent and child is developed through pleasurble satisfying interaction.
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Reciprocal attachment behaviors?
Make eye contact and engage in prolonged intense mutual gazing
move their eyes and attempt to track the parents face
grasp and hold the parents finger
Move synchronously in response to rhythms and patterns of the parents voice (Called entrainment)
Root latch on the the breast and suckle
Be comforted by the parents voice or touch
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What are the three puerperal phases ?
Takin-in
taking-hold
letting-go
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THe taking in phase?
the mother is focused primarliy on her own need for fluid food and sleep.
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THe taking-hold phase?
she exhibits concern about managin her owen body fucntions and assumes responsibility for her own care. When she feels more comfortable and in control of her body she shifts her attention to the behaviors of the infant.
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What has the taking-hold phase been called?
teachable reachable referable moment.
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The letting-go phase?
a time of relinquishment for the mother and often for the father.
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characteristics of postpartum blues?
last no longer than 2 weeks
insomnia
irritablitiy
fatigue
tearfulness
mood instability
anxiety
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