NURS 371 Exam 2 Questions and
Answers 100% Solved | Graded A+
1st Degree Lacerations (laceration degrees) - ✔✔Involves only skin and
superficial structures above muscle
2nd Degree Lacerations (laceration degrees) - ✔✔Extends through
perineal muscles
3rd Degree Lacerations (laceration degrees) - ✔✔Extends through the anal
sphincter muscle
4th Degree Lacerations (laceration degrees) - ✔✔Continues through
anterior rectal wall
Stages of Adaptation - ✔✔-Taking in phase
-Taking hold phase
-Letting go phase
Taking in Phase (stages of adaptation) - ✔✔-Time immediately after birth
when the client needs others to meet her needs & relives the birth process
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-Mother demonstrates dependent behaviors & assumes a passive role in
meeting own basic needs
Taking Hold Phase (stages of adaptation) - ✔✔-Second phase
characterized by dependent and independent maternal behavior
-Mother becomes preoccupied with the present
Letting Go Phase (stages of adaptation) - ✔✔-Third phase in which woman
reestablishes relationships with others
-Mother reestablishes relationships with others and demonstrates
increased responsibility & confidence in caring for the newborn
Episiotomy Care - ✔✔-Assess every 8 hours
-Apply ice to relieve discomfort & reduce edema (first measure)
-Sitz baths also can promote comfort and perineal healing (effective after
first 24 hours)
-Use peri-bottle to clean site & blot dry instead of rubbing
BUBBLEEE (postpartum assessment) - ✔✔-Breasts (size, contour,
engorgement)
-Uterus (height of fundus, firmness)
-Bladder (voiding, bladder emptying)
-Bowels (bowel sounds, distention)
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-Lochia (amount, color, odor)
-Episiotomy/Perineum & Epidural site (lacerations, hematoma)
-Extremities
-Emotional status
Risk Factors for Postpartum Infection (postpartum assessment) - ✔✔-
Operative procedure (forceps, cesarean birth, vacuum extraction)
-History of diabetes, including gestational-onset diabetes
-Prolonged labor (more than 24 hours)
-Use of indwelling urinary catheter
-Anemia (hemoglobin < 10.5 mg/dL)
-Multiple vaginal examinations during labor
-Prolonged rupture of membranes (>24 hours)
-Manual extraction of placenta
-Compromised immune system (HIV positive)
Risk Factors for Postpartum Hemorrhage (postpartum assessment) - ✔✔-
Precipitous labor (less than 3 hours)
-Uterine atony
-Placenta previa or abruptio placenta
-Labor induction or augmentation