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191 Cards in this Set
- Front
- Back
Puerperium
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time of adjustment when reproductive organs return to nearly pre-pregnant state; extends to 6-8 weeks after childbirth, "fourth trimester"
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What happens to blood volume, cardiac output, and clotting factors immediately after birth?
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Blood Volume: lessened (sweating)
CO: increases Clotting factors: increase (to protect from postpartum hemorrhage) |
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How often should you check the mother post partum?
1st hour? 2nd hour? 3-8 hours? every 8 hours thereafter? |
1st: every 15 minutes
2nd: every 30 minutes 3-8: every 1 - 2 hours Every 8 hours thereafter |
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True or false: taking a blood pressure can be painful for a woman in the puerperium period.
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True
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What would you expect for normal vitals for the mom immediately post-partum?
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Temp: up to 38C (100.4 F) 1st 24 hours
Tacycardia (early sign of excessive blood loss) BP: WNL |
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What could increased BP mean for the postpartum woman?
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Pre-eclampsia (if proteinuria + hypertension)
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What could decreased BP mean for the postpartum woman?
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Can be a late sign of hemorrage
Can cause Orthostatic hypotension |
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What is the normal EBL for vaginal birth?
Cesarean? |
vaginal: 100-500cc
C/S: 700-1000cc |
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How much does the hemoglobin drop per 500ml blood loss?
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2 points drop in hemoglobin
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What is considered an abnormal drop in hematocrit?
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>10%
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What hg/hct level is considered anemia?
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Less than or equal to 10/30
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What are common values of WBCs for the first 10-12 days postpartum?
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Elevated to 20,000-25,000
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How long do plasma fibrinogen and clotting factors remain at pregnancy levels?
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One week
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If someone has pre-eclampsia, they may also be hyper_______.
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Reflexive
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What could be signs of thrombus formation in the postpartum woman?
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Pain, tenderness, redness, warmth, calf size, edema, positive homan's sign
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What do varicosities mean postpartum?
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Swollen, distended veins, not neessaily a risk for thrombus formation
Can lead to redness, warmth and pain |
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The process by which the uterus shrinks(returns to non-pregnant state) is called ____.
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Involution
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How long does it take post partum until the uterus is not palpable?
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about 6 weeks
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Process of self digestion and reabsorption of the protein which had enlarged the uterine muscle cells.
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Autolysis
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A large number of cells remain after each pregnancy, resulting in a slight _____ in uterine size
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Increase
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Two medications that facilitate involution
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Methergine (sustained uterine contraction)
Pitocin (rhythmic uterine contractions) |
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4 things that facilitate involution
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Breastfeeding
Fundal massage Medications |
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8 factors that could interfere with involution
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Full bladder
Overdistended uterus Prolonged labor Difficult birth (more vag exams = more bacteria) Anesthesia Retained Placenta Grand Multipara Infection(uterine muscles don't work as well) |
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Why might a woman not know her bladder is full postpartum?
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Decreased sensitivity
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What are two causes of an oversidetended uterus?
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Multiple birth
Clots |
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Fundal height changed:
Immediately 12 hours Day 1-8 Day 9 5-6 weeks |
immediately: 2cm below umbilicus
by 12 hours: 1cm above umbilicus Day 1-8: decreases 1cm per day Day 9: not palpable 5-6 weeks: near pre-pregnant size |
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The bladder fills ______ with postpartum _____
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quickly, diuresis
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Two medications that facilitate involution
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Methergine (sustained uterine contraction)
Pitocin (rhythmic uterine contractions) |
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4 things that facilitate involution
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Breastfeeding
Fundal massage Medications |
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8 factors that could interfere with involution
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Full bladder
Overdistended uterus Prolonged labor Difficult birth (more vag exams = more bacteria) Anesthesia Retained Placenta Grand Multipara Infection(uterine muscles don't work as well) |
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Why might a woman not know her bladder is full postpartum?
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Decreased sensitivity
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What are two causes of an oversidetended uterus?
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Multiple birth
Clots |
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Fundal height changed:
Immediately 12 hours Day 1-8 Day 9 5-6 weeks |
immediately: 2cm below umbilicus
by 12 hours: 1cm above umbilicus Day 1-8: decreases 1cm per day Day 9: not palpable 5-6 weeks: near pre-pregnant size |
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The bladder fills ______ with postpartum _____
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quickly, diuresis
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5 nursing actions prior to and during feeling for post partum fundal height changes
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1 - Have pt. void
2 - lie mother flat 3 - palpate fundal height and location 4 - note any displacement 5 - evaluate consistency |
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3 interventions for post partum uterine bleeding
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1 - uterine massage
2 - breast feeding 3 - Medications |
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Which med is given to slow uterine bleeding for:
Low BP? High BP? |
Low - Methergine
High - Misoprostol (rectal) |
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How long do after birth pains last?
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2-3 days
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What causes after-birth pains?
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Hormones (Oxytocin and Prostaglandins)
Other factors (multiparous, over distended uterus, breast feeding, exogenous oxytocin) |
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What might be indicated if heavier bleeding continues with a firm uterus?
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lacerations
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5 interventions for after birth pain
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1 - warm compress
2 - alternative therapies 3 - Medications 4 - Keep bladder empty 5 - Reassure that it will lessen each day |
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When does the cervix return to it's original form?
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Within a few hours
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When is the os of the cervix fingertip sized?
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1 week
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What happens the the shape of the os after birth?
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Shape changes permanently to being more open and oval - "Parous"
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Why would you need to refit the diaphragm/cervical cap at 6-week postpartum check-up?
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Because the os permanently changes to being parous shape
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What is lochia?
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Discharge from shedding or soughing of decidua/lining of uterus
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How does the color of lochia change:
2-3 days? 3-10 days? 10-21 days? |
2-3 days: rubra (red some small clots)
3-10 days? serosa (pink/brown) 10-21 days? alba (yellow/clear) |
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A ___ amount of oozing with fundal massage may be noticed in the first few days postpartum.
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Small
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Lochia amounts:
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Scant <2.5 cm
Light<10cm Moderate >10cm Heavy - 1 pad saturated in less than 2 hours |
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Episiotomy is equivalent to _____ laceration
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2nd degree
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Which degree lacerations do not necessarily need repair (if not bleeding)?
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1st
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Which degree lacerations always need repair?
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2nd, 3rd, 4th
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First degree lacerations involve
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vaginal mucosa, posterior fourchette, perineal skin
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Second degree lacerations and episiotomy involve:
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Vaginal mucosa, posterior fourchette, perineal skin, and perineal muscles
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Third degree laceration
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Vaginal mucosa, posterior fourchette, perineal skin, perineal muscles, tear through entire thickness of analsphincter, muscle retracts into the surrounding tissue and can be difficult to see
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partial third degree laceration
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Sheering of muscle fibers of the sphincter and requires repair
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Fourth degree lacerations
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Extension of the third degree laceration into the mucosa of the rectum; skin of rectal sphincter is disrupted
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Post partum orders for perineal tears
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no suppository, no enema, "nothing per rectum"; can get order for stool softener
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REEDA Scale
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Rates 0-3 for each item: Redness, Edema, Ecchymosis, Discharge, Approximation
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What should a nurse also pay attention for when examining the perineum?
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Hemorrhoids
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Which position is best for visualizing the perineum?
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Side-lying
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What should you instruct a woman to do when urinating with perineal pain?
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Use a squeeze bottle, wipe front to back
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How should you instruct a woman to sit to reduce perineal pain?
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Tighten buttocks first; sit on firm surface
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What are 5 nursing interventions for perineal pain?
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Sitz bath after 24 hours, anesthetic spray, meds on regular schedule, ice 12-24 hours, offer stool softener
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5 interventions for hemorrhoids
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Increase hydration, increase freuits veggies and fiber, witch hazel pads after void, sitz bath for at lease 20 min, anesthetic spray or cream applied sparingly 3-4 times daily
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What are two instances in which you would use a sitz bath?
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Hemorrhoids, perineal pain
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What does a sitz bath do?
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improves blood flow to perineum and promotes healing
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Can be used at least _____ daily
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2 times; up to 5
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What kind of response are the chills and shakes?
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Neuro
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3 nursing interventions for chills/shakes
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keep blankets in warmer and have ready to go; reassure the mother that it is common; assure safety of baby
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What does diaphoresis do for the post partum woman?
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rids of extravascular fluid;
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Two nursing interventions for diaphoresis
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linen/gown change; protect against chilling
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3 things you should teach about 1st time getting out of bed:
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Effects of meds, rising slowly, holding baby
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Following a c-section, when should a women be getting up out of bed?
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Day of surgery
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What is enough of an exercise for a woman with distasis recti abdominis?
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chin to chest
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how do you measure the separation of the rectus abdominis?
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Fingerbreadths
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When are breasts:
Soft? Filling? Full? |
Soft - 0-48 hours
Filling 48 - 72 hours Full 72 hours |
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How long does engorgement discomfort last?
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24-36 hours?
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Differences in breast feeding and non breast feeding management of engorgement:
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Breast uses warm shower, non uses ice and avoids warm water
Breast nurses frequently, non does not express milk intentionally Non uses pain meds, breast does not |
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Similarities in management of engorgement for breast feeding and non breast feeding moms
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wear supportive bra 24 hrs/day
cabbage leaves |
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What puts a woman at risk for constipation during pregnancy and labor?
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less tone in pregnancy, prelabor diarrhea, dehydration, less intake in labor, analgesia/anesthesia, concern about perineal discomfort
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How long can it take for the first post partum BM?
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2-3 days
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What can a nurse do to encourage a BM in a postpartum woman?
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Fiber, fluids, food, activity, stool softeners (c/s and 3rd and 4th tears)
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How can you help a post c/s woman avoid flatus pain?
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clear liquids then diet as tolerated (usu 2nd day
avoid gas forming foods and carbonated beverages, lie of left side use rocking chair Encourage activity |
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There is decreased ____ and ____ of urinary system post partum
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tone and dilation
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How long does it take for urinary dilation to return to normal? Tone?
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2 weeks to 2 months; 1 week
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How much does a woman diurese in the first 24 hours?
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2000-3000cc
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What are factors that contribute to urinary retention?
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dereased sensation, anesthesia, swelling/bruising of perineum, periurethral laceration, overly full bladder
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When should a woman first void? and how frequently thereafter?
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1-2 hours; every 2-4 hours
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What should you monitor regarding urinary elimination in a postpartum c/s woman?
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I and O after foley is out, incomplete emptying (retenntion with over flow), measure voids (3 > 250 or 1 > 500), observe for signs of UTI, drink lots and void often
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When should a woman void after a normal spontaneous vaginal delivery?
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within 8 hours
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What are 6 interventions you can use with a NVSD woman post partum to help her void?
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Peppermint oil, hand in warm water, running water, assist to bathroom, spray perineum with water, provide perineal pain relief if that is causing retention
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Interventions for altered tissue perfusion in post partum woman
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Exercises for circulation (q 15 min in recovery, q shift postpartum), support hose, early ambulation
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What can contribute to altered family processes?
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Separation from neonate pos c/s, pain, IVs, challenges with breastfeeding, disappointment with birth experience
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When do you give the rubella vaccine?
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If the titer is <1:8
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When do you avoid the rubella vaccine?
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Immunocompromised persons, allergy to duck eggs
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How long should you avoid pregnancy if you receive the rubella vaccine?
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1 month
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When is RHOgam given?
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Within 72 hours of birth
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What is the normal length of postpartum hospital stay for vaginal delivery?
C/S? |
48 hours; 96 hours
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What are the criteria for early discharge?
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-healthy mom w/o complications during pregnancy, birth and post partum
-term infant, healthy infant with normal lab and vitals -social and physical environemtn support continued wellness of mother and infant -Documentation of mother's ability to care for and feed infant -Follow up scheduled within 1 week if discharged before 48 hours |
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How much weight is lost with the birth of the baby? Diuresis?
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10-12 pounds; 5 pounds
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How long should a woman wait before starting calorie restriction for weight loss?
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6 weeks.
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When does amenorrhea stop?
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Non breast feeding: 6-10 weeks
Breast feeding: 4--7 months (up to a year) |
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What percent of 1st cycles are anovulatory?
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50%
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What suppresses ovarian function post partum in breast feeding woman?
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prolactin
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Can ovulation occur before 1st menstruation?
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YES!
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The vagina is ______ and _____ post delivery
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edematous and congested
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When do vaginal rugae return?
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3-6 weeks?
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Return of pelvic floor muscle tone may take ____
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Months
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________ cause thin mucosa and vaginal dryness
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Low estrogen levels
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Thin mucosa and vaginal dryness last longer with which type of feeding?
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breast feeding
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If perineum is intact, Intercourse is safe when lochia is: rubra, serosa, alba? How long?
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Alba, 2-4 weeks
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How long should you wait to have sex following extensive perineal repair?
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6 weeks
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Sexual responses may take a few months to return and may be ____ and ____ ______
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slower and less intense.
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how long does it take for abdominal tone to return with exercise?
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2-3 months
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Suggested abdominal exercises
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pelvic tilt
partial sit ups walking prone position |
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How much weight can c/s mom lift for first 6 weeks?
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Only weight of baby
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4 major post partum complications
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hemorrhage, infections, embolic phenomena, mental health
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What is the leading cause of maternal death and morbidity?
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Postpartum hemorrhage
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Define postpartum hemorrhage:
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blood loss of > 500 ml after birth
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How are women able to compensate for fluid loss post partum?
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They have a good fluid reserve - overload in pregnancy that is protective.
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What is Early and Late Postpartum hemorrhage?
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Early: 1st 24 hours
Late: 2nd day up to 4 weeks |
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Four causes of postpartum hemorrhage
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Uterine atony
Lacerations Retained placental fragments Clotting problems |
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8 factors associated with atony
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1 - overdistended uterus
2 - Gradmultiparity 3 - Anesthesia 4 - Rapid labor 5 - long labor 6 - Pitocin use in labor 7 - MgSO4 use in labor 8 - Ruptured uterus |
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7 signs of hypovolemic shock
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1 - BP decreases
2 - Pulse increases 3 - Cool and clammy skin 4 - Grayish or ashen skin 5 - Anxiety/Air-hunger 6 - Complaints of weakness, light headedness or nausea 7 - Persistent significant bleeding |
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5 medications for atony
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Pitocin
Methergine Ergotrate Prostin Cytotec |
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5 Nursing interventions for hemorrhage prevention/cessation
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IV for high risk women
Assess for lacerations External manual compression Oxygen Fundus, lochia, and bladder assessment |
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What causes a postpartum hematoma?
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Hidden laceration
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What is a postpartum hematoma?
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collection of blood from an injured blood vessel in soft, connective tissue
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4 factors that contribute to postpartum hematoma
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Pelvic congestion of pregnancy
anesthesia Large infant Difficult delivery (forceps, position) |
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How can you tell the difference between edema and a hematoma?
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Use a flashlight: edema is translucent
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6 symptoms of a postpartum hematoma
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Excessive pain at wound site
Feeling of vaginal pressure Firm, painful to touch Pain out of proportion to what one would expect Bluish or redding discoloration Change in vital signs |
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6 interventions for post-hemorrhage care
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Assistance with self-care
Safety for mom and baby Rest Fluids Nutrition Vitamin and mineral supplements |
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Post-hemorrhagem would you encourage or discourage oral fluids?
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Encourage
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4 things to monitor in post-hemorrhage care
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BP
Pulse Fundal height and firmness Temperature |
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Why would surgery be required post-hemorrhage?
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To clean out the uterus
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2 Serious complications of hemorrhage
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Hypovolemic shock
DIC |
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When would you order antibiotics post-hemorrhage?
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If the woman had a fever
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How can DIC be treated?
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Correct underlying cause
Use anticoagulants Replace blood components Oxygen Fluids |
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What factors contribute to DIC?
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Hemorrhage
Sepsis Severe preeclampsia Abruption Dead fetus syndrome Amniotic fluid embolsim |
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Factors that put a woman at risk for post partum infection:
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Traumatic birth
Multiple vaginal exams Underlying disease (Diabetes) Stasis Vaginal flora altered Prolonged ROM |
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4 signs/symptoms of uterine infection
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foul odor
bleeding tenderness subinvolution |
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Preventative measures: respiratory infection
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check lungs every 4-8 hours
Cough and deep breath Ambulate Incentive spirometer |
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Preventing postpartum infections:
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Hand washing
Sterile technique when necessary perineal care Limit vaginal exams Timely delivery Prophylactic antibiotics for C/S |
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Major sign of endometritis
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subinvolution
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2 causes of endometritis
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Retained placental fragments
Infection |
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4 symptoms of endometritis
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Lochia rubra for more than 2 weeks
Fundal height higher than expected Tender, boggy uterus S/S infection |
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Should a nurse use a regular urine specimen to test for proteinuria or hematuria?
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No - May need to cath for a specimen, because of lochia in GU tract
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When is the surgical dressing removed from the c/s site? When can a woman shower?
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24 hours; after dressing is removed
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A foley in for how long puts a woman at risk of UTI?
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8-24 hours
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Do UTIs tend to manifest early or late?
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Late - 2-3 weeks
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3 medications for endometritis
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methergine
Antibiotics Iron supplements |
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3 organisms that cause mastitis
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Staph Aureus
E. Coli Yeast |
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Is mastitis common?
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No. Less than 1% of women
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6 contributing factors to mastitis
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Damaged nipples
trauma to breastFatigue Stress Milk stasis Poor drainage (blocked duct) |
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T/F Mastitis usually only happens in the first 5 days of breast feeding
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False. Can happen anytime during lactation
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Symptoms of mastitis
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Fever (over 101)
Reddened,warm, swollen area Flu-like symptoms Chills Headache |
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Nursing interventions for mastitis
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Prevention
Rest Fluids Frequent nursing Local heat Analgesics Antibiotics Supportive bra |
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4 types of postpartum embolic phenomena
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Pulmonary embolus
Amniotic Fluid Embolus Deep Vein Thrombosis Superficial vein thrombosis |
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Why do clotting factors alter during pregnancy?
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To prevent hemorrhage
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7 factors contributing to thrombophlebitis
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Altered clotting factors during pregnancy
Inactivity C/S Multipara Over 35 years old Obesity Smoker |
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Treatment for thrombophlebitis
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Rest
Elevation of legs Analgesia heat Support hose anticoagulants |
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Pulmonary embolus
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dislodged clot that circulates to lung; blocks blood flow of to a portion of lung
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Symptoms of pulmonary embolus:
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Chest pain
Apprehension Shortness of breth Tachycardia Hypotension Diaphoresis Atelectasis |
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Contributing factors to amniotic fluid embolus:
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Tumultuous labor
Oxytocin with hypertonic contractions AROM |
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Symptoms of amniotic fluid embolus
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Chest pain
Dyspnea Cyanosis Frothing at mouth** Tachycardia Hypotension Hemorrhage |
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What percent of women get the baby blues?
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75-80%
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When are baby blues usually noted?
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2-10 days, peaks at day 5
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What percent of women have postpartum depression?
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10-15%
|
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What is the recurrence rate of postpartum depression?
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70%
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What percent of women have postpartum psychosis?
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0.1 - 0.4%
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What is the recurrence rate of postpartum psychosis?
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25%
|
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When do baby blues set in? How do they resolve?
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Within 1st few days; resolve without treatment
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What are common signs of a woman with baby blues?
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Cries easily
Fatigued Disrupted sleep |
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To be considered depression, how long does sadness persist?
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More than 2 weeks postpartum
|
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Characteristics of postpartum depression
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Severe mood swings
Irritability Intense fears and anxieties Ruminations of tuilt and inadequace Anger Thoughts of harming baby and or slef May appear healthy |
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What increases risk of post partum depression?
|
History of depression
|
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What kind of help does a woman suffering from postpartum depression need?
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Professional help/counselling
Maybe meds |
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What does postpartum psychosis begin with?
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Usually begins with severe depression (fatigue, insomnia, restlessness, emotional liability)
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Characteristics of postpartum psychosis
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Dilusions (break with reality; auditory hallucinations)
Incoherence/Irrational statements Paranoia/Suspiciousness Complains of inability to move, stand, work |
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When is the onset of postpartum psychosis?
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Usually 2-3 weeks postpartum; almost always within 8 weeks postpartum
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Bonding
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Parent to infant
Immediately after birth Eye contact, body movement High risk infant or mother influences |
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Attachment
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Infant to parent, and parent to infant
First year of life quality/ timing of experiences influence infant: sucking, clinging crying, smiling, etc. |
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Attachment definition
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enduring twoway bond or relationship of affection between persons
|
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Engrossment
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father's absorption in infant
|
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3 stages of father-infant attachment
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Expectations
Reality Transition to mastery |
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Which maternal role development stage is the optimal teaching time?
|
Taking hold
|
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What are the three maternal role development stages?
|
Taking in 1-2 days
Taking hold 3 days - weeks Letting go 7-10 days+ |
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In which maternal role development stage does the mom focus on herself and her own needs?
|
Taking in
|
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In which maternal role development stage does the woman start to focus more on the whole family?
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Letting go
|
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When may a woman feel socially isolated?
|
Letting go stage
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