lOMoAR cPSD| 63316909
NR 327
Exam 2 Content Review Sheet
Textbook Chapters: 14, 17, 19, 20, 21, 22
ATI Chapters: 17, 18, 19, 22, 23, 24, 25, 26
****Not all inclusive****
Fetal Heart Monitor (distress, interventions) & FHM Strips
• Normal FHR: 110-160 Accelerations:
o Temporary increase o Reassuring no interventions
• Early deceleration: mirror mom’s contractions
o Cause: compression of baby’s head on
pelvis/soft tissue o Normal – no
interventions, expected finding
• Late deceleration: responds after contraction
o Cause: uteroplacental insufficiency o
Non-reassuring needs intervention
o Nursing interventions: side-lying position, IV fluids, discontinue oxytocin,
administer O2, palpate uterus for tachysystole (more frequent intense
contractions), notify provider
• Variable deceleration: not uniform look for Vs
o Cause: cord compression o Requires
intervention
o Nursing interventions: knee-chest position or side-side repositioning, discontinue
oxytocin, administer O2, notify provider
• REMEMBER VEAL CHOP MINE
V – variable C – cord compression M – move side left
E – early decels H – head compression I – identify labor progression
A – acceleration O – OK N – no intervention
L – late decels P – placental insufficiency E – execute immediately STOP = stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased
• Fetal bradycardia: FHR drops below 110 for at least 10 minutes o Causes: uteroplacental
insufficiency, umbilical cord prolapses, maternal hypotension, anesthetic meds mom
received
o Interventions: stop oxytocin, left side position, O2, notify provider
• Fetal tachycardia: FHR increases above 160 for over 10 minutes o Causes: infection,
cocaine use, dehydration
, lOMoAR cPSD| 63316909
o Interventions: antipyretics, oxygen, IV fluid bolus
• The contractions:
o Increment: beginning, building of pressure
o Acme: most intense part of the contraction
o Decrement: diminishing of the contraction
o Rest: period of time between contractions
BUBBLE HER
• Breasts:
o Inspect for size, contour, asymmetry, engorgement, or erythema o
Check the nipples for cracks, redness, fissures, or bleeding
Note if they are erect, flat, or inverted
• Uterus:
o Assess the fundus to determine the degree of uterine involution
Have the woman empty her bladder first before assessing the fundus o
Fundus should be midline and should not feel boggy or relaxed
o 1-2 hours after birth, the fundus is between the umbilicus & the symphysis pubis
o 6-12 hours birth, the fundus is usually at the level of the umbilicus
o The fundus progresses downward at a rate of 1 fingerbreadth or 1 cm per day after
childbirth
o On the first postpartum day, the top of the fundus is located 1 cm below the
umbilicus and is recorded as U/1
o If the fundus is NOT firm, then gently massage the uterus using a circular motion
until it becomes firm
• Bladder:
, lOMoAR cPSD| 63316909
o Assess the bladder for distention & adequate emptying after efforts to void
o If the bladder is full, lochia drainage will be more than normal b/c the uterus
cannot contract to suppress the bleeding
o Note the location & condition of the fundus – a full bladder tends to displace the
uterus up & to the right
o Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 mL), discomfort, burning, urgency, or foul-smelling urine
• Bowels:
o Spontaneous bowel movements may NOT occur for 2-3
days after giving birth b/c of a decrease in muscle tone in
the intestines during labor
o Normal patterns of bowel elimination usually return within
8-14 days after birth o Inspect the woman’s abdomen for
distention, auscultate for bowel sounds in all 4 quadrants,
& palpate for tenderness
o Ask the woman if she has had a bowel movement or has
passed gas since giving birth
• Lochia:
o Assess the amount, color, and odor of lochia
Ask about the # of perineal pads used in the past 2-4
hours & how much drainage was on each pad
Color:
• Rubra/red: 1-3 days
• Serosa/pink: 3-10 days
• Alba/white: 10-14 days
o The amount of lochia on perineal pad is described as follows:
Scant: 1-2-inch lochia stain or approx. a 10 mL loss
Light or small: an approx. 4-inch stain or a 10-25 mL loss
Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
Large or heavy: a pad is saturated within 1 hour after changing it o
Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
fragments or a foul odor to the physician
o Teach patient about frequent changing of perineal pads, continuous use of the
peribottle, and proper handwashing before & after changing the pad
Episiotomy/Perineum:
o Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas
o Assess for hemorrhoids & their condition
o Redness, swelling, increasing discomfort, or purulent drainage may indicate
infection
o Ice can be applied to relieve discomfort & reduce edema o Sitz baths can
also promote comfort & perineal healing
NR 327
Exam 2 Content Review Sheet
Textbook Chapters: 14, 17, 19, 20, 21, 22
ATI Chapters: 17, 18, 19, 22, 23, 24, 25, 26
****Not all inclusive****
Fetal Heart Monitor (distress, interventions) & FHM Strips
• Normal FHR: 110-160 Accelerations:
o Temporary increase o Reassuring no interventions
• Early deceleration: mirror mom’s contractions
o Cause: compression of baby’s head on
pelvis/soft tissue o Normal – no
interventions, expected finding
• Late deceleration: responds after contraction
o Cause: uteroplacental insufficiency o
Non-reassuring needs intervention
o Nursing interventions: side-lying position, IV fluids, discontinue oxytocin,
administer O2, palpate uterus for tachysystole (more frequent intense
contractions), notify provider
• Variable deceleration: not uniform look for Vs
o Cause: cord compression o Requires
intervention
o Nursing interventions: knee-chest position or side-side repositioning, discontinue
oxytocin, administer O2, notify provider
• REMEMBER VEAL CHOP MINE
V – variable C – cord compression M – move side left
E – early decels H – head compression I – identify labor progression
A – acceleration O – OK N – no intervention
L – late decels P – placental insufficiency E – execute immediately STOP = stop
Pitocin, turn patient on side, O2 via face mask, plain IV fluid increased
• Fetal bradycardia: FHR drops below 110 for at least 10 minutes o Causes: uteroplacental
insufficiency, umbilical cord prolapses, maternal hypotension, anesthetic meds mom
received
o Interventions: stop oxytocin, left side position, O2, notify provider
• Fetal tachycardia: FHR increases above 160 for over 10 minutes o Causes: infection,
cocaine use, dehydration
, lOMoAR cPSD| 63316909
o Interventions: antipyretics, oxygen, IV fluid bolus
• The contractions:
o Increment: beginning, building of pressure
o Acme: most intense part of the contraction
o Decrement: diminishing of the contraction
o Rest: period of time between contractions
BUBBLE HER
• Breasts:
o Inspect for size, contour, asymmetry, engorgement, or erythema o
Check the nipples for cracks, redness, fissures, or bleeding
Note if they are erect, flat, or inverted
• Uterus:
o Assess the fundus to determine the degree of uterine involution
Have the woman empty her bladder first before assessing the fundus o
Fundus should be midline and should not feel boggy or relaxed
o 1-2 hours after birth, the fundus is between the umbilicus & the symphysis pubis
o 6-12 hours birth, the fundus is usually at the level of the umbilicus
o The fundus progresses downward at a rate of 1 fingerbreadth or 1 cm per day after
childbirth
o On the first postpartum day, the top of the fundus is located 1 cm below the
umbilicus and is recorded as U/1
o If the fundus is NOT firm, then gently massage the uterus using a circular motion
until it becomes firm
• Bladder:
, lOMoAR cPSD| 63316909
o Assess the bladder for distention & adequate emptying after efforts to void
o If the bladder is full, lochia drainage will be more than normal b/c the uterus
cannot contract to suppress the bleeding
o Note the location & condition of the fundus – a full bladder tends to displace the
uterus up & to the right
o Be alert for signs of infection, including infrequent or insufficient voiding (less
than 200 mL), discomfort, burning, urgency, or foul-smelling urine
• Bowels:
o Spontaneous bowel movements may NOT occur for 2-3
days after giving birth b/c of a decrease in muscle tone in
the intestines during labor
o Normal patterns of bowel elimination usually return within
8-14 days after birth o Inspect the woman’s abdomen for
distention, auscultate for bowel sounds in all 4 quadrants,
& palpate for tenderness
o Ask the woman if she has had a bowel movement or has
passed gas since giving birth
• Lochia:
o Assess the amount, color, and odor of lochia
Ask about the # of perineal pads used in the past 2-4
hours & how much drainage was on each pad
Color:
• Rubra/red: 1-3 days
• Serosa/pink: 3-10 days
• Alba/white: 10-14 days
o The amount of lochia on perineal pad is described as follows:
Scant: 1-2-inch lochia stain or approx. a 10 mL loss
Light or small: an approx. 4-inch stain or a 10-25 mL loss
Moderate: a 4-6-inch stain w/ an estimated loss of 25-50 mL
Large or heavy: a pad is saturated within 1 hour after changing it o
Report any abnormal findings, such as heavy, bright-red lochia w/ large tissue
fragments or a foul odor to the physician
o Teach patient about frequent changing of perineal pads, continuous use of the
peribottle, and proper handwashing before & after changing the pad
Episiotomy/Perineum:
o Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas
o Assess for hemorrhoids & their condition
o Redness, swelling, increasing discomfort, or purulent drainage may indicate
infection
o Ice can be applied to relieve discomfort & reduce edema o Sitz baths can
also promote comfort & perineal healing
