Rasmussen - MCN - Exam 2 Correct
Questions & Answers!!!
Lochia Rubra (red) - ANSWER Lochia _______ is mostly blood, fragments of decidua,
and mucus and starts in postpartum days 1-3
Lochia serosa (pink/brown) - ANSWER Lochia _____ is blood, mucus, and invading
leukocytes and starts in postpartum days 3-10.
Lochia Alba (white to yellow-white) - ANSWER Lochia ______ is non-odorous, mucus-
like, with high leukocyte counts and starts in postpartum days 10-14 days (can last 6
weeks.)
•The greatest risk in postpartum stage is *hemorrhage, shock, and infection* - ANSWER
The greatest risks to a postpartum mom
Oxytoxics - ANSWER ___________ medications can be given to help promote
contraction of the uterus thus decreasing bleeding and chances of hemorrhage
*afterpains*
▪ breastfeeding increases the afterpains as oxytocin is released with nipple stimulation. -
ANSWER ________are the contractions pains that help with involution of the uterus
(similar to menstrual cramps.)
▪ they can be much more painful for multiparas women and those with an over
distended uterus (polyhydramnios, multiple gestations, macrosomic infant, etc.).
▪ they are usually not as bad after the first few days.
▪ Lochia amount varies greatly from woman to woman.
▪ Mothers who breastfeed tend to have less lochial discharge than those who do not
because the natural release of the hormone oxytocin during breastfeeding strengthens
uterine contractions.
▪ Lochial flow increases on exertion, especially the first few times a woman is out of bed
but decreases again with rest.
▪ Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow
and should be reported.
▪ Don't use tampons to halt the flow or this could lead to infection. - ANSWER Lochia
Evaluation - *Amount*
▪ Lochia should contain no exceedingly large clots as these may indicate a portion of the
placenta has been retained and is preventing closure of the maternal uterine blood
sinuses.
,▪ In any event, large clots denote poor uterine contraction, which needs to be corrected.
- ANSWER Lochia Evaluation - *Consistency*
▪ Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown from days 4 to 10
(lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth.
▪ The pattern of lochia (rubra to serosa to alba) should not reverse as this suggests a
placental fragment has been retained or uterine contraction is decreasing and new
bleeding is beginning. - ANSWER Lochia Evaluation - *Pattern*
▪ Lochia should not have an offensive odor as this suggests the uterus has become
infected.
▪ Immediate intervention is needed to halt postpartal infection. - ANSWER Lochia
Evaluation - *Odor*
▪ Lochia should never be absent during the first 1 to 3 weeks as absence of lochia, like
presence of an offensive odor, may indicate postpartal infection.
▪ Lochia may be scant in amount after cesarean delivery, but it is never altogether
absent. - ANSWER Lochia Evaluation - *Absence*
•Scant - less than 2.5cm
•Light - less than 10cm
•Moderate - more than 10cm
•Heavy - one pad saturated within 2 hours
•Excessive - one pad saturated in 15mins or less - ANSWER Name the 5 types of lochia
amounts and their measurements
*It decreases by one fingerbreadth, or 1 cm, per day*
▪ Right after birth it's at the umbilicus
▪ For example, on the first postpartal day, it will be palpable 1 cm below the umbilicus.
▪ In the average woman, by the ninth or tenth day, the uterus will have contracted so
much that it is withdrawn into the pelvis and can no longer be detected by abdominal
palpation - ANSWER Postpartum: *Fundal Height Changes*
▪ Palpate the fundus of the uterus by placing one hand on the base of the uterus, just
above the symphysis pubis, and the other at the umbilicus.
▪ Press in and downward with the hand at the umbilicus until you "bump" against a firm
globular mass in the abdomen: the uterine fundus - ANSWER How do you palpate the
fundus?
episiotomy - ANSWER incision made into the perineum to enlarge the vaginal opening
to help with delivery
laceration - ANSWER a tear during labor
, •Promote measures for the client to help soften her stool (stool softeners or high fiber
foods like fruit, fluids)
•Sitz baths
•NO Enemas or Suppositories
•Analgesics
•Ice packs for comfort
•Educate on proper cleaning to prevent infection
- wash hands before and after
- use squeeze bottle filled with warm water after each void to cleanse perineal area
- clean from front to back
- blot dry not wipe - ANSWER Nursing Care: *Laceration/Episiotomy*
•If fundus is displaced, then the bladder needs to be emptied.
•Pressure from the trauma of delivery cause urinary retention so it is important to
monitor I&O and to promote getting up and using the restroom every 2-3 hours -
ANSWER Postpartum: *Bladder Assessment*
epidurals
spinal tap
urinary catheters
vaginal swelling/trauma from birth - ANSWER Causes of *Urinary Retention*
mastitis - ANSWER Is an infection of the breast involving the interlobular connective
tissue and is usually unilateral
•Localized heat and swelling
•Pain; tender axillary lymph nodes
•Elevated temperature
•Complaints of flulike symptoms
"wedge"
•When mastitis is the issue, your symptoms may be similar to having a clogged duct,
but they will be more intense, especially if the clogged duct is the reason for the
mastitis. Because the symptoms are so similar, it is important to start treating the clog
as soon as you notice it - ANSWER S/S: *Mastitis*
•Milk stasis from blocked duct
•Nipple trauma
•Poor breastfeeding techniques
•Poor hygiene - ANSWER Risk Factors: *Mastitis*
clogged (blocked or plugged) duct - ANSWER when one the of the many milk ducts in
the breast are obstructed and the milk flow is stopped or slowed.
Questions & Answers!!!
Lochia Rubra (red) - ANSWER Lochia _______ is mostly blood, fragments of decidua,
and mucus and starts in postpartum days 1-3
Lochia serosa (pink/brown) - ANSWER Lochia _____ is blood, mucus, and invading
leukocytes and starts in postpartum days 3-10.
Lochia Alba (white to yellow-white) - ANSWER Lochia ______ is non-odorous, mucus-
like, with high leukocyte counts and starts in postpartum days 10-14 days (can last 6
weeks.)
•The greatest risk in postpartum stage is *hemorrhage, shock, and infection* - ANSWER
The greatest risks to a postpartum mom
Oxytoxics - ANSWER ___________ medications can be given to help promote
contraction of the uterus thus decreasing bleeding and chances of hemorrhage
*afterpains*
▪ breastfeeding increases the afterpains as oxytocin is released with nipple stimulation. -
ANSWER ________are the contractions pains that help with involution of the uterus
(similar to menstrual cramps.)
▪ they can be much more painful for multiparas women and those with an over
distended uterus (polyhydramnios, multiple gestations, macrosomic infant, etc.).
▪ they are usually not as bad after the first few days.
▪ Lochia amount varies greatly from woman to woman.
▪ Mothers who breastfeed tend to have less lochial discharge than those who do not
because the natural release of the hormone oxytocin during breastfeeding strengthens
uterine contractions.
▪ Lochial flow increases on exertion, especially the first few times a woman is out of bed
but decreases again with rest.
▪ Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow
and should be reported.
▪ Don't use tampons to halt the flow or this could lead to infection. - ANSWER Lochia
Evaluation - *Amount*
▪ Lochia should contain no exceedingly large clots as these may indicate a portion of the
placenta has been retained and is preventing closure of the maternal uterine blood
sinuses.
,▪ In any event, large clots denote poor uterine contraction, which needs to be corrected.
- ANSWER Lochia Evaluation - *Consistency*
▪ Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown from days 4 to 10
(lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth.
▪ The pattern of lochia (rubra to serosa to alba) should not reverse as this suggests a
placental fragment has been retained or uterine contraction is decreasing and new
bleeding is beginning. - ANSWER Lochia Evaluation - *Pattern*
▪ Lochia should not have an offensive odor as this suggests the uterus has become
infected.
▪ Immediate intervention is needed to halt postpartal infection. - ANSWER Lochia
Evaluation - *Odor*
▪ Lochia should never be absent during the first 1 to 3 weeks as absence of lochia, like
presence of an offensive odor, may indicate postpartal infection.
▪ Lochia may be scant in amount after cesarean delivery, but it is never altogether
absent. - ANSWER Lochia Evaluation - *Absence*
•Scant - less than 2.5cm
•Light - less than 10cm
•Moderate - more than 10cm
•Heavy - one pad saturated within 2 hours
•Excessive - one pad saturated in 15mins or less - ANSWER Name the 5 types of lochia
amounts and their measurements
*It decreases by one fingerbreadth, or 1 cm, per day*
▪ Right after birth it's at the umbilicus
▪ For example, on the first postpartal day, it will be palpable 1 cm below the umbilicus.
▪ In the average woman, by the ninth or tenth day, the uterus will have contracted so
much that it is withdrawn into the pelvis and can no longer be detected by abdominal
palpation - ANSWER Postpartum: *Fundal Height Changes*
▪ Palpate the fundus of the uterus by placing one hand on the base of the uterus, just
above the symphysis pubis, and the other at the umbilicus.
▪ Press in and downward with the hand at the umbilicus until you "bump" against a firm
globular mass in the abdomen: the uterine fundus - ANSWER How do you palpate the
fundus?
episiotomy - ANSWER incision made into the perineum to enlarge the vaginal opening
to help with delivery
laceration - ANSWER a tear during labor
, •Promote measures for the client to help soften her stool (stool softeners or high fiber
foods like fruit, fluids)
•Sitz baths
•NO Enemas or Suppositories
•Analgesics
•Ice packs for comfort
•Educate on proper cleaning to prevent infection
- wash hands before and after
- use squeeze bottle filled with warm water after each void to cleanse perineal area
- clean from front to back
- blot dry not wipe - ANSWER Nursing Care: *Laceration/Episiotomy*
•If fundus is displaced, then the bladder needs to be emptied.
•Pressure from the trauma of delivery cause urinary retention so it is important to
monitor I&O and to promote getting up and using the restroom every 2-3 hours -
ANSWER Postpartum: *Bladder Assessment*
epidurals
spinal tap
urinary catheters
vaginal swelling/trauma from birth - ANSWER Causes of *Urinary Retention*
mastitis - ANSWER Is an infection of the breast involving the interlobular connective
tissue and is usually unilateral
•Localized heat and swelling
•Pain; tender axillary lymph nodes
•Elevated temperature
•Complaints of flulike symptoms
"wedge"
•When mastitis is the issue, your symptoms may be similar to having a clogged duct,
but they will be more intense, especially if the clogged duct is the reason for the
mastitis. Because the symptoms are so similar, it is important to start treating the clog
as soon as you notice it - ANSWER S/S: *Mastitis*
•Milk stasis from blocked duct
•Nipple trauma
•Poor breastfeeding techniques
•Poor hygiene - ANSWER Risk Factors: *Mastitis*
clogged (blocked or plugged) duct - ANSWER when one the of the many milk ducts in
the breast are obstructed and the milk flow is stopped or slowed.
