Maternity Lab Exam

BUBBLLEE

• breasts

• uterus

• bowels

• bladder

• legs

• lochia

• episiotomy

• emotional status

Breast assessment

Size, color, discharge, soft or firm, shape, temperature, fullness, heaviness

Uterus assessment

Palpate fundus, should be one finger breadth below umbillicus on day one. Every day, it should be an additional finger breadth. Should not be painful. Should be firm. If fundus is deviated the bladder could be full. Fundal massage and breastfeeding can stimulate contractions in the fundus

Bowels assessment

Has she had a BM, was it painful

Bladder assessment

Check I+O, ask her if she has been voiding, is she at risk for urinary retention, if she is having trouble voiding she may need an in and out catheter

Legs assessment

Does she have any edema? Can be normal, especially after a c-section or if she was given fluids. Should go away when the legs are elevated. Edema should not be excessive or pitting. If it is pitting, grade the edema. Redness, heat, and tenderness can indicate deep vein thrombosis

Lochia assessment

Vaginal discharge. Happens after all births, regardless if it was c-section or vaginal. Lochia rubra, serosa, and alba. Rubra is red, happens for the first while after birth. Then turns pink, then white. Tell them not to flush clots. We want to look at their clots and make sure they are not more than the size of a toonie (can be retained placenta). Lochia can have a slight odor, but should not be foul smelling.

Episiotomy assessment

Vaginal tearing. Can be present during a vaginal birth, or c-section if vaginal birth was attempted. Determine the degree of the tear

Emotional status assessment

Assess how mom is coping and how they are bonding with the baby. Hormonal swings and being emotional is normal, but they should still be interested in the baby

Peri bottle

Recommended for use after voiding, mom can take it home with her

How long is a cool pad recommended for use after birth?

Only for 24 hours. Not recommended past that. Only used to relieve vaginal swelling after birth

When can mom shower after birth?

Whenever she feels like it

When can mom bath after birth?

Baths are not recommended for 6 weeks after birth

What type of monitoring should be used if the pregnancy is not high risk?

Intermittent auscultation

Why do we not use EFM with normal pregnancies?

The chance for c-section increases with EFM

Non-stress test

Hooking mom up to HR monitor when not in labor, to see baby’s HR

Baseline FHR

110-160BPM

Fetal bradycardia

HR below 110 for at least 10 minutes

Fetal tachycardia

HR above 160 for at least 10 mins

Variability

Fluctuation in baseline FHR, up to 25 BPM

Variability above 25 BPM

abnormal

Variability below 25 BPM

normal

Accelerations

When FHR rises by 15BPM or more from the baseline, for at least 15 seconds

When do accelerations usually happen?

With contractions

Decelerations

When FHR drops by 15BPM or more from the baseline, for at least 15 seconds

When are accelerations or decelerations considered prolonged?

when they occur for 2 minutes or longer

When do early decels happen

WITH contractions

When do late decels happen

AFTER contraction

Are early decels normal?

yes

are late decels normal?

NO

Late decels nursing interventions

• Change moms position

• Give mom ice chips or popsicle (something cold to wake up baby)

• Check transducer to make sure they are on correctly

• Check moms radial pulse to ensure the machine is not picking up moms HR instead of babys

• Ask doctor if fluids can be ordered

• Give oxygen

• Ask mom to stop or modify her pushing

• Perform vaginal exam to rule out cord prolapse

Tachysystole

More than 5 contractions in 10 mins or less

How long of a break should mom have between contractions

2 minutes

What is a possible cause of tachysystole?

Oxytocin drips

Tachysystole nursing intervention

Stop oxytocin drips

Can acels or decels come from other acels or decels?

No, must come from the baseline

Can RNs change epidural dressings?

NO, must ask physician/anesthetist

Epidural nursing interventions

• Monitor V/S, especially blood pressure and RR. Should be frequent.

• Monitor for overdose

• Have narcan on hand

• Administer narcan

Types of epidurals

• Opioid

• Analgesic

• Combined

What can a RR of less than 10 indicate in a patient with an epidural?

Can indicate overdose

What else should the nurse monitor for with epidurals?

• Nerve damage

• Infection

• Urinary retention

• Pruritis (can give benadryl)

• Bleeding at the site

• Systemic toxcitiy (convulsions)

How would the nurse assess the dermatomes of a person with an epidural?

• Put ice on the not sedated part

• Then put ice on the sedated part

• See which dermatomes do not have sensation

• If the patient has no sensation at T4 and above, CALL DOCTOR RIGHT AWAY

PCA (Patient controlled anesthetic)

Patient can control meds PRN. Meds are flowing continuously, but they have a top up button if they want to increase the dose by certain amounts.

Has a lock out period, where the patient can not receive any more med.

Check pump screen to see how many requests the patient made, and how many doses were actually delivered. (Patient may be in more pain, or may not know how to use the button)

Wound assessment

• Discharge

• Drainage

• Redness

• Edema

• Infection

• Pain

• Warmth

• Tissue granulation (if healing)

• Necrotic or slough

• Odor

• Dehiscence (wound reopening)

Pre-Suture and staple removal steps

• Review order in chart to remove

• Check history

• Assess bleeding risk

• Pain level

Staple removal procedure steps

• Prepare supplies

• hand hygeine and introduction

• Leave staple remover in package (do not add to field)

• Apply gloves

• Remove old dressing

• Assess wound (do not touch actual wound)

• Create triangle shape working space (working table, patient, garbage)

• Open sterile dressing tray

• Grab 1 forcep

• Take out sterile drape

• Lay drape down. Can touch outside 1 inch borders

• Get normal saline (if it splashes start sterile tray over)

• Grab second forcep

• Make pillows with forceps and dip in saline

• Wipe top of wound - throw in garbage

• Wipe bottom of wound - throw in garbage

• Wipe centre of wound - throw in garbage

• Dry wound in same order - top, bottom, centre

• Get staple remover and place bottom under staple, top above and pull staple out

• Place staple on gauze

• Count staples taken out

• Recleanse wound

• Can cover with gauze and tape, write on the gauze, if doctor has not requested it be uncovered

Suture removal procedure steps

• Set up and cleaning same as staples

• Use forceps to grab knot

• Use scissor to cut close to skin, not knot

• Pull suture out

• If opening is greater than 2 staples/sutures, use steri strips to hold wound closed

What should the nurse make sure the patient does regularly when on oxygen therapy?

Take deep breaths and cough regularly

What should the nurse give the patient if they feel like their sutures are going to bust when they cough

Give pillow (splint) to hold against incision

What can the nurse instruct the patient to do during deep breathing to decrease pneumonia risk

Breathe deeply, on the third inhale hold their breath for 3 seconds, then cough 3 times

Incentive spirometry nursing interventions

• Measure oxygen saturation before and after

• Instruct patient to take big inhale and exhale

• Do it 3 times, average out results

• Can make it harder by adjusting level

• The highest of the three tries is what the nurse adjusts the level to, the patient tries to beat that level the next time

Trach suctioning steps

• Use water to clean line

• Monitor oxygen saturation before and after suctioning

• Move vaccuum around until all secretions are cleared

What is oxygen therapy used for

Hypoxia (can be r/t chronic illness, emphysema, lung cancer, and more) or respiratory depression (post surgery)

Oxygen therapy things the nurse should educate patient about

• place sign outside door indicating oxygen is in use

• must be 10 ft away from heat and fire sources at all time

• person can be flammable

• no smoking around the person

What does the nurse assess for when the patient is on oxygen therapy

• cyanosis

• anxiety

• confusion

• skin breakdown

• burns from O2 sat monitor

Oxygen saturation nursing considerations

• rotate oxygen saturation monitoring sites every 4 hours to prevent burns

• can be inaccurate for different ethnicites due to skin color

types of oxygen therapy

• Low flow nasal cannula

• Simple face mask

• Bag mask

• Face tent

• Venturi mask

• CPAP

low flow nasal cannula

• can hook directly to wall

• good for short term use

simple face mask

• good for 5-10L/min

• good for short term use

• cant eat with it on

bag mask

• patient is breathing in FULL oxygen

• higher oxygen saturation

Face tent

• placed by the person

• good for confused people while theyre sleeping

Venturi mask

• has different parts you can attach

• each part delivers a different saturation of oxygen

• each part has the percent of oxygen and the volume to turn machine to labelled on it

CPAP

• continuous positive airway pressure

• keeps the airway open

• good flor sleep apnea

• sometimes used in ICU

• can be used in place of ventilating and traching to keep the airway open

WHO and UNICEF breastfeeding recommendations

• Initiate breastfeeding within the first hour of life

• Breastfeeding exclusively for the first 6 months

• Breastfeed without use of artificial nipples

• Breastfeed up to 2 years and beyond

Benefits of breastfeeding for babies

• antibodies

• fat, protein and vitamins

• custom made for baby’s needs

• decreased likelihood of obesity and diabetes

• decreased ear infections, upper respiratory infections

• lowers risk of SIDS

Benefits of breastfeeding for mom

• decreased risk of breast and ovarian cancer, osteoporosis, postpartum depression, and postpartum hemmorhage

• increases self confidence and efficacy

• increases mother-infant bonding

forms of breastfeeding

• Exclusive breastfeeding

• exclusive pumping

• combination/mixed feeding

• donor milk

benefits of skin to skin

• thermoregulation

• maintains blood sugar (cold babies drop blood sugar)

• promotes bonding

• milk-making hormones

• decreases pain response during painful procedures

• promotes baby’s newborn reflexes

Best time to do breastfeeding and skin to skin after birth?

Within the first hour of life. baby is more alert and awake

why might babies not breastfeed well in their first day of life?

they are tired. this is expected and normal

lactogenesis

milk coming in

what can affect lactogenesis?

• disuse of one side can result in milk not being produced in that side

• retained placenta can delay milk

• bad latch - when baby suckles, oxytocin is released

milk within first 1-3 days is called?

colostrum (contains minerals, vitamins, immunoglobulin)

milk within first 2-4 days is called?

transitional milk (breast milk with some colostrum)

milk after 7+ days is called?

mature milk (90% water with some proteins and fat)

how might baby feed in the 24-48 hours after birth?

may show frequent feeding cues, may cluster feed

How to perform hand expression

• fingers an inch back from the nipple

• push back towards chest wall

• gently compress

newborn feeding cues

• hands to mouth

• sucking

• sticking out tongue

• rooting

• head bobbing

• active arms

• want to feed at early feeding cues, not late (when baby is crying)

how often do newborns feed

around 8 times a day, sometimes more

Breastfeeding positions

• tummy to mommy

• cradle hold

• cross cradle hold

• football hold

• side lying

• can use pillows to support mom so she does not get tired

LATCH

L - lips flanged (especially bottom lip)

A - asymmetric latch (nipple points up in mouth towards the soft palate

T - tummy towards mommy

C - chin touching breast and comfort

H - hear and see nutritive sucking (swallows)

deep latch

• nipple is far back in baby’s mouth

• mouth is wide open

short/shallow latch

tongue cannot reach under the nipple

signs feeding is going well

• output (at least 6 heavy wet diapers after day 5 (before that about 1 wet diaper for each day of life) (at least 3 BMs a day)

• weight (babies lose weight in first days)

• activity (baby should be alert and active when not sleeping, should be content after feeds)

What size in and out catheter is typically used for an adult?

14-16 inches

position for female catheter

dorsal recumbent

position for male catheter

supine

how far to lubricate female catheter

1-2 inches

how far to lubricate male catheter

2-4 inches

midstream urine sample

dont use the first drops of the urine. catch urine at the middle of the stream

how many mL collected for midstream urine sample

5-10mL

nagele’s rule

First day of LMP. Subtract 3 months. Add 7 days. Add 1 year

Leopold’s maneuvers steps

1. palpate fundus - determine what part of fetus is at the fundus

2. palpate each side of abdomen - find out which side contains the spine and which contains the limbs

3. palpate above symphysis pubis - locate presenting part, how descended it is

4. confirm presentation - apply pressure to fundus and verify presenting part

What color nitrazine paper test indicates amniotic fluid

dark blue

how often should parents clean the baby’s umbillical cord, and how?

during every diaper change. clean with a q tip and ONLY water

best sleep position for baby?

back is best, in a crib with no blankets, pillows, toys, bumpers, etc

what solution is used to irrigate a catheter

normal saline

Should normal saline be used to inflate a urinary catheter balloon?

NO. normal saline can cause crystals in the balloon system and prevent deflation. use sterile water

What is residual urine?

urine that is leftover in the bladder after the patient has voided

When is the most likely time for wound dehiscence or evisceration to occur

approximately 6-8 days after the surgery