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HESI MATERNITY STUDY GUIDE EXAM 2
12 (309) , 13 (337) , 15 (375) , 16 (417)
Postpartum blues and depression
Post partum Blues (4 weeks)
o Depression can lead to psychosis
Few days after delivery
Tearfulness, anorexia, difficulty sleeping, feeling of letdown, sadness
Resolves in 10 to 14 days
Caused by:
Hormones, psych adjustments, unsupportiveness, insecurity, fatigue,
discomfort, & over stimulation
Post partum Depression
o 6-12 months PP
o Whole family
o Requires psychiatric intervention
o Unable to safely care for baby
Use of PPD screening before discharge
Taking in, taking hold, letting go, bonding, attachment (maternal)
Taking in - 1 to 2 days after delivery
◦ Mother is passive and somewhat dependent as she sorts reality from fantasy in birth
experience
◦ Food and sleep are major needs
◦ Focus on herself
Taking hold - 2 to 3 days after delivery
◦ Mother ready to resume control over her life
◦ She is focused on baby and may need reassurance
◦ Baby blues
Letting go- 3 days beyond
◦ Taking home
◦ Independence to new mother role
◦ Grieving and letting go of old relationship behavior
◦ Incorporates newborn into life
◦ Accepts the newborn
◦ Independence –work or school
Postpartum assessment and interventions, pathophysiology, BUBBLE HEER , proper techniques of
assessment
▪ Vital signs, pain, breath sounds
, 2
▪ Laboratory findings, such as, CBC, rubella status, and Rh status
▪ Breasts
▪ Uterus
▪ Bladder
▪ Bowel
▪ Lochia
▪ Episiotomy, lacerations, perineum, hemorrhoids
▪ Lower extremities
▪ Emotions, bonding with infant, fatigue
Post partum changes
Know baseline
Involution takes 6 weeks
o Rapid reduction in size of uterus to pre pregnant state
Uterus is at level of umbilicus within 6 to 12 hours after child birth
Decreases by one finger breadth per day
BUBBLE HEE R
R- Rhogam: Blood product administered at 28 weeks important to give within 72 hours after
delivery
Bowel, bladder, perineum, extremities
Assess frequency, burning, urgency palpate for bladder distention
Bowel: bowel sounds, flatus, distention
Inspect incision & perineum for: REEDA
Assess hemorrhoids
Extremities
o Pedal edema, redness, warmth
o Homan’s sign
Perineum
Incision or lacerations may occur during delivery
Assess for approx., edema, hematoma, hemorrhoids, bruising, excessive pain, and odor
Clean front to back
Peri-bottle should be used
For pain: ice packs, witch hazel pads, and anesthetic spray may be used with oral analgesics, &
sitz bath
Assess “REEDA”
R- Redness
E- Edema
E- Ecchymosis (bruise)
D- Discharge
A- Approximation of episiotomy or repaired laceration edges
, 3
Episiotomy
Midline: Vertical surgical incision to perineum, extending the vaginal opening
Mediolateral: R or L diagonal surgical incision to perineum
o Extension to 3rd or 4th degree
Lacerations
1° Laceration: Superficial tear of the perineal skin and vagina (may or may not require repair)
2° Laceration: Involvement of the perineal/vaginal muscles (requires sutures to repair)
3° Laceration: Through the perineal muscles to the anal sphincter
4° Laceration: Through the perineal muscles and through the anal sphincter and the rectal tissues
Peri-urethral: Lacerations near the urethra
Vaginal (sulcus), cervical, and labial
Nursing interventions
Ice 1st 24 hours
Lie on side decrease pressure on the perineum
Tighten gluteal muscles as she sits down to relax muscles
o Cushions the perineum and increases comfort in sitting position
Wear peripads snugly to prevent rubbing
Use of peri bottle and warm sitz bath p 24 hrs
Lochia Assessment
Rubia
o 1-3 days
o Fleshy odor
o Small clots
Serosa
o 4-10 days
o Pink or brown color
o Scant amount
o Fleshy odor
Alba
o Day 10
o Yellow to white in color
o Scant amount
o Fleshy odor
Deviation
o Bright red bleeding, heavy amounts, regression, & foul odor
*If bleeding from serosa to rubia or alba to serosa fever, chills, urinary frequency, swelling, foul odor,
redden harden area on breast (Mestitis), depression, and don’t want to be with baby call physician
HESI MATERNITY STUDY GUIDE EXAM 2
12 (309) , 13 (337) , 15 (375) , 16 (417)
Postpartum blues and depression
Post partum Blues (4 weeks)
o Depression can lead to psychosis
Few days after delivery
Tearfulness, anorexia, difficulty sleeping, feeling of letdown, sadness
Resolves in 10 to 14 days
Caused by:
Hormones, psych adjustments, unsupportiveness, insecurity, fatigue,
discomfort, & over stimulation
Post partum Depression
o 6-12 months PP
o Whole family
o Requires psychiatric intervention
o Unable to safely care for baby
Use of PPD screening before discharge
Taking in, taking hold, letting go, bonding, attachment (maternal)
Taking in - 1 to 2 days after delivery
◦ Mother is passive and somewhat dependent as she sorts reality from fantasy in birth
experience
◦ Food and sleep are major needs
◦ Focus on herself
Taking hold - 2 to 3 days after delivery
◦ Mother ready to resume control over her life
◦ She is focused on baby and may need reassurance
◦ Baby blues
Letting go- 3 days beyond
◦ Taking home
◦ Independence to new mother role
◦ Grieving and letting go of old relationship behavior
◦ Incorporates newborn into life
◦ Accepts the newborn
◦ Independence –work or school
Postpartum assessment and interventions, pathophysiology, BUBBLE HEER , proper techniques of
assessment
▪ Vital signs, pain, breath sounds
, 2
▪ Laboratory findings, such as, CBC, rubella status, and Rh status
▪ Breasts
▪ Uterus
▪ Bladder
▪ Bowel
▪ Lochia
▪ Episiotomy, lacerations, perineum, hemorrhoids
▪ Lower extremities
▪ Emotions, bonding with infant, fatigue
Post partum changes
Know baseline
Involution takes 6 weeks
o Rapid reduction in size of uterus to pre pregnant state
Uterus is at level of umbilicus within 6 to 12 hours after child birth
Decreases by one finger breadth per day
BUBBLE HEE R
R- Rhogam: Blood product administered at 28 weeks important to give within 72 hours after
delivery
Bowel, bladder, perineum, extremities
Assess frequency, burning, urgency palpate for bladder distention
Bowel: bowel sounds, flatus, distention
Inspect incision & perineum for: REEDA
Assess hemorrhoids
Extremities
o Pedal edema, redness, warmth
o Homan’s sign
Perineum
Incision or lacerations may occur during delivery
Assess for approx., edema, hematoma, hemorrhoids, bruising, excessive pain, and odor
Clean front to back
Peri-bottle should be used
For pain: ice packs, witch hazel pads, and anesthetic spray may be used with oral analgesics, &
sitz bath
Assess “REEDA”
R- Redness
E- Edema
E- Ecchymosis (bruise)
D- Discharge
A- Approximation of episiotomy or repaired laceration edges
, 3
Episiotomy
Midline: Vertical surgical incision to perineum, extending the vaginal opening
Mediolateral: R or L diagonal surgical incision to perineum
o Extension to 3rd or 4th degree
Lacerations
1° Laceration: Superficial tear of the perineal skin and vagina (may or may not require repair)
2° Laceration: Involvement of the perineal/vaginal muscles (requires sutures to repair)
3° Laceration: Through the perineal muscles to the anal sphincter
4° Laceration: Through the perineal muscles and through the anal sphincter and the rectal tissues
Peri-urethral: Lacerations near the urethra
Vaginal (sulcus), cervical, and labial
Nursing interventions
Ice 1st 24 hours
Lie on side decrease pressure on the perineum
Tighten gluteal muscles as she sits down to relax muscles
o Cushions the perineum and increases comfort in sitting position
Wear peripads snugly to prevent rubbing
Use of peri bottle and warm sitz bath p 24 hrs
Lochia Assessment
Rubia
o 1-3 days
o Fleshy odor
o Small clots
Serosa
o 4-10 days
o Pink or brown color
o Scant amount
o Fleshy odor
Alba
o Day 10
o Yellow to white in color
o Scant amount
o Fleshy odor
Deviation
o Bright red bleeding, heavy amounts, regression, & foul odor
*If bleeding from serosa to rubia or alba to serosa fever, chills, urinary frequency, swelling, foul odor,
redden harden area on breast (Mestitis), depression, and don’t want to be with baby call physician
