NSG 3500 TEST QUESTIONSAND ANSWERS A+
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What is included in the early maternal assessment?
- V/S
- fundal assessment (always support lower uterus)
- lochia assessment
- perineum assessment
A temp of 100.4 is normal for a PP mom. T/F?
True
When does early PPH occur?
Usually within the first 4 hours
What are the S/S of early PPH?
- tachycardia (>110 bpm)
- 15% drop in BP
- decreased O2 sats <95%
What is the most common cause of PPH?
Uterine atony
A continuous trickle of bright red blood w/o clots and firm uterus indicates what
type of trauma in PPH?
Unrepaired lacerations
A patient complains of unrelieved pain or pressure in the perineal or vaginal area.
You may or may not be able to see the injury. It can be caused by forceps
delivery. What is the condition?
Hematoma
*tx is similar to PPH
What medications do we use for PPH?
1. oxytocin (20U in 1000mL of LR or NS)(do not overdo as it can cause further uterine
atony)
2. cytotec (rectal or sublingual)
3. methergrine (do NOT give if hypertensive or preeclamptic)
4. hemabate (do NOT give if pt has asthma, cardiac, liver, or kidney issues)
When does late PPH occur?
>24hrs but within 2 weeks
What is a common cause of late PPH?
Uterine atony r/t retained placental fragments
Ice packs do not cause constriction of milk ducts. T/F?
False. Ice packs can cause constriction of milk ducts so use cautiously.
How should bottle feeding mothers treat their breasts?
Encourage tight breast binding and do not squeeze milk out.
When do breasts become engorged after birth?
- engorgement occurs by day 4
- colostrum is the first milk
- breasts begin filling by about day 3
, How should the nurse assess the breasts?
- inspect nipples: are they flat, everted, inverted?
- is the breast tissue soft, filling, or firm?
- assess temp and color of breasts overall
What do we assess in the uterus post-partum?
- normal involution (natural progression of the uterus returning to its pre-pregnancy
state)
- is the uterus midline or deviated?
- what is the tone like? is it firm, firm with massage, or boggy?
- are afterpains present?
What do we assess in the GI/GU system?
- light colored urine is expected r/t high vol of fluids
- COLA assessment
- is the bladder distended?
- is flatus present?
- assess bowel sounds
What type of lochia is expected days 1-3?
Lochia rubra [bright red and blood clots are normal]
What do we assess when it comes to lochia post-partum?
- color (rubra, serosa, and alba)
- amount (scant, light, moderate, heavy)
- presence of clots
What type of lochia is expected days 4-10?
Lochia serosa [thin in density, turns from red to pinkish-brown, contains mucus, less
flow with fewer clots, flow is ongoing]
What type of lochia is expected days 10-14?
Lochia alba [changes from pinkish-brown to a yellowish-white, contains little red blood,
no odor or no real flow]
We use R.E.E.D.A. to inspect:
episiotomy, tearing, hematoma formation, and hemorrhoids.
How can we address discomfort post-partum?
- NSAIDs, opioids can be given but may be avoided due to constipation
- unilateral leg pain needs to be reported to MD
- sitz baths
- hot and cold application
- witch hazel pads
What do we look for when assessing the legs for venous thrombosis?
- pulses
- pain
- edema
- warmth
- sensation
- varicosities
Returning to pre-pregnancy state looks like...
- decreased blood volume
- decreased estrogen, progesterone
GRADED.Buy Quality Materials!
What is included in the early maternal assessment?
- V/S
- fundal assessment (always support lower uterus)
- lochia assessment
- perineum assessment
A temp of 100.4 is normal for a PP mom. T/F?
True
When does early PPH occur?
Usually within the first 4 hours
What are the S/S of early PPH?
- tachycardia (>110 bpm)
- 15% drop in BP
- decreased O2 sats <95%
What is the most common cause of PPH?
Uterine atony
A continuous trickle of bright red blood w/o clots and firm uterus indicates what
type of trauma in PPH?
Unrepaired lacerations
A patient complains of unrelieved pain or pressure in the perineal or vaginal area.
You may or may not be able to see the injury. It can be caused by forceps
delivery. What is the condition?
Hematoma
*tx is similar to PPH
What medications do we use for PPH?
1. oxytocin (20U in 1000mL of LR or NS)(do not overdo as it can cause further uterine
atony)
2. cytotec (rectal or sublingual)
3. methergrine (do NOT give if hypertensive or preeclamptic)
4. hemabate (do NOT give if pt has asthma, cardiac, liver, or kidney issues)
When does late PPH occur?
>24hrs but within 2 weeks
What is a common cause of late PPH?
Uterine atony r/t retained placental fragments
Ice packs do not cause constriction of milk ducts. T/F?
False. Ice packs can cause constriction of milk ducts so use cautiously.
How should bottle feeding mothers treat their breasts?
Encourage tight breast binding and do not squeeze milk out.
When do breasts become engorged after birth?
- engorgement occurs by day 4
- colostrum is the first milk
- breasts begin filling by about day 3
, How should the nurse assess the breasts?
- inspect nipples: are they flat, everted, inverted?
- is the breast tissue soft, filling, or firm?
- assess temp and color of breasts overall
What do we assess in the uterus post-partum?
- normal involution (natural progression of the uterus returning to its pre-pregnancy
state)
- is the uterus midline or deviated?
- what is the tone like? is it firm, firm with massage, or boggy?
- are afterpains present?
What do we assess in the GI/GU system?
- light colored urine is expected r/t high vol of fluids
- COLA assessment
- is the bladder distended?
- is flatus present?
- assess bowel sounds
What type of lochia is expected days 1-3?
Lochia rubra [bright red and blood clots are normal]
What do we assess when it comes to lochia post-partum?
- color (rubra, serosa, and alba)
- amount (scant, light, moderate, heavy)
- presence of clots
What type of lochia is expected days 4-10?
Lochia serosa [thin in density, turns from red to pinkish-brown, contains mucus, less
flow with fewer clots, flow is ongoing]
What type of lochia is expected days 10-14?
Lochia alba [changes from pinkish-brown to a yellowish-white, contains little red blood,
no odor or no real flow]
We use R.E.E.D.A. to inspect:
episiotomy, tearing, hematoma formation, and hemorrhoids.
How can we address discomfort post-partum?
- NSAIDs, opioids can be given but may be avoided due to constipation
- unilateral leg pain needs to be reported to MD
- sitz baths
- hot and cold application
- witch hazel pads
What do we look for when assessing the legs for venous thrombosis?
- pulses
- pain
- edema
- warmth
- sensation
- varicosities
Returning to pre-pregnancy state looks like...
- decreased blood volume
- decreased estrogen, progesterone
