NUR 335 Exam 3 Arizona College of Nursing-Las Vegas | UPDATED
Questions with 100% Verified Answers
Question:
What is the acronym for post partum assessments?
Answer:
B- breasts
U- uterus
B- bladder
B- bowel
L- lochia
E- episiotomy/lacerations/hemorrhoids
L- lower extremities
E- emotions/bonding/psychosocial
Question:
What are abnormal BUBBLEE assessment findings?
Answer:
- Breasts: mastitis, extreme pain with breastfeeding, cracking or bleeding, engorgement
for more than 2 days
- Uterus: difficult to palpate, boggy, tender/excess contractions, uncentered, at or above
umbilicus, afterpains for more than 3 days (primipara)
- Bladder: bladder palpable/distended, cystitis (urgency/burning), incontinence more
than 6 hours PP
- Bowel: constipation more than 3 days PP, hemorrhoids, n/v
- Lochia: rubra pad saturation within 1 hour, foul odor, placental fragments in lochia
- Episiotomy: bruising, excess edema, discharge, tender, erythema, pain
- Lower extremities: tender, warm to touch, painful, edema, 2+ or greater DTR (indicates
severe HTN), weak pulses, DVT
- Emotions: bonding issues, fatigue, PPD, thoughts of harming self or others
Question:
What are some cardiovascular changes in the PP period?
assessment?
, Answer:
- QBL: Vaginal delivery < 500 mL; C-section <1000 mL; both within 24 hours
- DTV: increased risk because of decreased plasma volume and high clotting factors up
to 2 weeks PP
- Orthostatic hypotension: due to decreased vascular resistance in the pelvis and anemia
(Hgb < 11 and Hct < 32%)
- PP chills: feeling cold and shaky for a few hours PP due to vascular instability
Question:
cardiovascular assessment frequency in PP?
Answer:
- check pulse and BP every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 4
hours for 1 day, then once a shift if there are no complications until discharge
Question:
What are some respiratory changes in the PP period?
Answer:
- increased risk for pulmonary edema due to oxytocin, IV fluids, tocolytics, multiples,
infection, pre-e, and increased bedrest
Question:
respiratory assessment frequency in PP?
Answer:
- assess RR and breath sounds every 15 minutes for first hour, every 30 minutes for
second hour, every 4 hours for next 22 hours, and every shift after first day PP
Question:
What are some immune system considerations associated with
PP?
Answer:
- mild hyperthermia w/in first 24 hrs PP (anything above 100.4 F or 38 C may indicate
infection)
- Rubella: non-immune moms should receive vaccine before discharge and should avoid
pregnancy for 4 weeks after administration
, - Rhogam: given to Rh- moms to prevent antibody production
- Tdap, flu, Hep B, and varicella vaccines should also be given if indicated (avoid preg for
4 weeks)
Question:
What actions are appropriate if the PP mom has an elevated
temp?
Answer:
< 100.4 F= encourage fluids (64 oz./day) and rest
>100.4 F= same as above + notify physician and anticipate antibiotics
Question:
What are some common alterations in the urinary system in
the PP pariod?
Answer:
- transient stress incontinence (up to 6 weeks)
- bladder distention related to IV fluids, decreased sensation, urethral edema,
lacerations, operative vaginal delivery, bladder trauma
- urine output up to 3000 mL/day due to diuresis
- cystitis= bladder inflammation or infection
Question:
What are some nursing interventions for PP bladder care?
Answer:
- assist w/ voiding 2-4 hours post birth
- assess
- measure output (minimum of 300 mL 2-4 hr after delivery)
- catheterization if unable to void spontaneously
- admin antibiotics, fluids, and rest for cystitis
Question:
What are some endocrine changes associated with the PP
period?
Questions with 100% Verified Answers
Question:
What is the acronym for post partum assessments?
Answer:
B- breasts
U- uterus
B- bladder
B- bowel
L- lochia
E- episiotomy/lacerations/hemorrhoids
L- lower extremities
E- emotions/bonding/psychosocial
Question:
What are abnormal BUBBLEE assessment findings?
Answer:
- Breasts: mastitis, extreme pain with breastfeeding, cracking or bleeding, engorgement
for more than 2 days
- Uterus: difficult to palpate, boggy, tender/excess contractions, uncentered, at or above
umbilicus, afterpains for more than 3 days (primipara)
- Bladder: bladder palpable/distended, cystitis (urgency/burning), incontinence more
than 6 hours PP
- Bowel: constipation more than 3 days PP, hemorrhoids, n/v
- Lochia: rubra pad saturation within 1 hour, foul odor, placental fragments in lochia
- Episiotomy: bruising, excess edema, discharge, tender, erythema, pain
- Lower extremities: tender, warm to touch, painful, edema, 2+ or greater DTR (indicates
severe HTN), weak pulses, DVT
- Emotions: bonding issues, fatigue, PPD, thoughts of harming self or others
Question:
What are some cardiovascular changes in the PP period?
assessment?
, Answer:
- QBL: Vaginal delivery < 500 mL; C-section <1000 mL; both within 24 hours
- DTV: increased risk because of decreased plasma volume and high clotting factors up
to 2 weeks PP
- Orthostatic hypotension: due to decreased vascular resistance in the pelvis and anemia
(Hgb < 11 and Hct < 32%)
- PP chills: feeling cold and shaky for a few hours PP due to vascular instability
Question:
cardiovascular assessment frequency in PP?
Answer:
- check pulse and BP every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 4
hours for 1 day, then once a shift if there are no complications until discharge
Question:
What are some respiratory changes in the PP period?
Answer:
- increased risk for pulmonary edema due to oxytocin, IV fluids, tocolytics, multiples,
infection, pre-e, and increased bedrest
Question:
respiratory assessment frequency in PP?
Answer:
- assess RR and breath sounds every 15 minutes for first hour, every 30 minutes for
second hour, every 4 hours for next 22 hours, and every shift after first day PP
Question:
What are some immune system considerations associated with
PP?
Answer:
- mild hyperthermia w/in first 24 hrs PP (anything above 100.4 F or 38 C may indicate
infection)
- Rubella: non-immune moms should receive vaccine before discharge and should avoid
pregnancy for 4 weeks after administration
, - Rhogam: given to Rh- moms to prevent antibody production
- Tdap, flu, Hep B, and varicella vaccines should also be given if indicated (avoid preg for
4 weeks)
Question:
What actions are appropriate if the PP mom has an elevated
temp?
Answer:
< 100.4 F= encourage fluids (64 oz./day) and rest
>100.4 F= same as above + notify physician and anticipate antibiotics
Question:
What are some common alterations in the urinary system in
the PP pariod?
Answer:
- transient stress incontinence (up to 6 weeks)
- bladder distention related to IV fluids, decreased sensation, urethral edema,
lacerations, operative vaginal delivery, bladder trauma
- urine output up to 3000 mL/day due to diuresis
- cystitis= bladder inflammation or infection
Question:
What are some nursing interventions for PP bladder care?
Answer:
- assist w/ voiding 2-4 hours post birth
- assess
- measure output (minimum of 300 mL 2-4 hr after delivery)
- catheterization if unable to void spontaneously
- admin antibiotics, fluids, and rest for cystitis
Question:
What are some endocrine changes associated with the PP
period?
