NUR 230 Maternity Exam 2 With
Correct Answers
Changes in Reproductive system: Uterus -(correct answer)Involution - return
of uterus to prepregnant state Uterus may rise above the umbilicus by 1cm
within the first 12 hours Within 24 hours should be at umbilicus (the level of a
20 week gestation) Uterine involution should occur at a rate of 1-2 cm per day
and at 2 weeks postpartum should not be felt externally BUBBLEEE
Assessment -(correct answer)Breasts Uterus Bladder Bowel Lochia Episiotomy
Epidural Site Emotional Status PROMOTING RECOVERY AND SELF-CARE
(Activity and Rest) -(correct answer)•Encourage early and frequent
ambulation •Rest as much as possible, sleep when infant sleeps PROMOTING
RECOVERY AND SELF-CARE (Nourishment) -(correct answer)•Formula Feeding
Mom •Breastfeeding Mom PROMOTING RECOVERY AND SELF-CARE
(Elimination) -(correct answer)•Voiding Patterns •Bowel Patterns PROMOTING
RECOVERY AND SELF-CARE (Perineal Care) -(correct answer)•Perineal Hygiene
•Topical Medications •Ice Packs •Sitz Baths Bladder and Bowel -(correct
answer)•COCA- Color, odor, consistency, amount; Time of last void/BM
•Distended bladder •Flatus •Auscultate bowel sounds Lochia -(correct
answer)•Rubra- 1-4 days, bright red •Serosa- 4-10 days, pink to brown •Alba-
10 days to 6 weeks, white to yellowish •Odor similar to menstrual flow, foul
odor indicates infection •Presence of clots Early postpartum hemorrhage -
(correct answer)•Within first 24 hours •Most common cause is uterine atony
Early Postpartum Hemorrhage Risk Factors -(correct answer)-macrosomia -
multiple gestation -polyhydramnios -chorioamnionitis -prolonged labor -use of
Magnesium sulfate -use of oxytocin (Pitocin) Early postpartum hemorrhage
observation -(correct answer)•Unrepaired lacerations of perineum or vaginal
canal •Monitor for continuous trickle of bright red blood •Hematoma's of
perineal area or vaginal -patient complains of unrelieved pain or pressure -
may or may not be able to see -can be caused by forceps or vacuum delivery
Postpartum Medications -(correct answer)•oxytocin (Pitocin) 20 U in 1000ml
of LR or NS •methylergonovine maleate (Methergine) dose: 0.2mg/ q4/ x6 IM
PO 0.2 mg q 4 Check Blood Pressure: DO NOT give if hypertensive Postpartum
medications (prostaglandins) -(correct answer)Prostaglandins: •Misoprostol
(Cytotec)- rectally, sublingual, buccal, or PO x1 •Carboprost Tromethamine
(Hemabate)- IM or intrauterine q15-90 minutes up to 8 doses •Dinoprostone
(Prostin E2)-rectally (contraindicated for hypotension) • •Side effects: nausea,
vomiting and diarrhea Late Postpartum Hemorrhage -(correct answer)•More
, than 24 hrs but less than a week after birth •Common cause- retained
placenta After the first postpartum day the most common cause of uterine
atony is retained placental fragments. The nurse must check for the presence
of fragments in lochia Endocrine Changes -(correct answer)1. Estrogen,
cortisol, placental enzyme insulinase reverse the diabetogenic effects of
pregnancy which means mom will need less insulin (If type I diabetic) 2.
Estrogen and progesterone levels drop markedly and reach rock bottom at 1
week PP which is the main cause of breast engorgement 3. Diuresis - release
extracellular water that is accumulated during pregnancy Pituitary and
Ovarian Function -(correct answer)•Prolactin blood levels rise progressively
throughout pregnancy - In those patients who decide to breast feed they
remain high •First ovulation after delivery varies •1. Ovulation can occur as
early as day 27 PP •2. Non lactating women have a mean time of about 10
weeks •3. Breastfeeding women have a mean time of about 6 months •This is
NOT A FORM OF BIRTH CONTROL Changes in Urinary Elimination -(correct
answer)•Within 12 hours of delivery women begin to lose excess tissue fluid
•Caused by decreased estrogen levels and removal of increased venous
pressure in the lower extremities •Blood loss with normal delivery also aids in
removal of extra fluid •Due to anesthesia and birth trauma to the urethra the
woman may experience a decreased need to void - encourage to void •May
have profuse diaphoresis first 2-3 days. Can void up to 3000mL/day to reduce
volume increase that occurred during pregnancy •Patient should void within 4
hours of delivery •Monitor closely for urine retention if voiding is frequent and
<100mL per voiding UTI -(correct answer)•Increased risk for UTI due to -
decreased urge to void -trauma during birth •Teach signs & symptoms of UTI
to report to PHCP •Teach preventative measures GI changes -(correct
answer)•Appetite changes and mom is typically very hungry after delivery
•May not have BM for 2-3 days due to: 1. decreased muscle tone in intestines
during labor 2. pre labor diarrhea 3. lack of food 4. dehydration 5. fear of pain
•Rectal sphincter tear -may experience some incontinence •Stool softeners
such as Colace given •Instruct on diet to prevent constipation Breast Changes
-(correct answer)•Colostrum is a clear/yellow fluid, first 2-3 days •Milk comes
in at around 72 - 96 hours •Wear supportive bra 24 h Breastfeeding Mothers -
(correct answer)•Feed infant every 2-3 hours •If engorgement occurs feed
baby first then pump or express, but if breasts are too full for latch, may need
to express a little first. •Warm compresses or shower may help •Plugged milk
duct- swollen, tender area -warm compress prior to feeding -feed on affected
side first -pump •Proper latch on important to prevent sore, cracked nipples
Correct Answers
Changes in Reproductive system: Uterus -(correct answer)Involution - return
of uterus to prepregnant state Uterus may rise above the umbilicus by 1cm
within the first 12 hours Within 24 hours should be at umbilicus (the level of a
20 week gestation) Uterine involution should occur at a rate of 1-2 cm per day
and at 2 weeks postpartum should not be felt externally BUBBLEEE
Assessment -(correct answer)Breasts Uterus Bladder Bowel Lochia Episiotomy
Epidural Site Emotional Status PROMOTING RECOVERY AND SELF-CARE
(Activity and Rest) -(correct answer)•Encourage early and frequent
ambulation •Rest as much as possible, sleep when infant sleeps PROMOTING
RECOVERY AND SELF-CARE (Nourishment) -(correct answer)•Formula Feeding
Mom •Breastfeeding Mom PROMOTING RECOVERY AND SELF-CARE
(Elimination) -(correct answer)•Voiding Patterns •Bowel Patterns PROMOTING
RECOVERY AND SELF-CARE (Perineal Care) -(correct answer)•Perineal Hygiene
•Topical Medications •Ice Packs •Sitz Baths Bladder and Bowel -(correct
answer)•COCA- Color, odor, consistency, amount; Time of last void/BM
•Distended bladder •Flatus •Auscultate bowel sounds Lochia -(correct
answer)•Rubra- 1-4 days, bright red •Serosa- 4-10 days, pink to brown •Alba-
10 days to 6 weeks, white to yellowish •Odor similar to menstrual flow, foul
odor indicates infection •Presence of clots Early postpartum hemorrhage -
(correct answer)•Within first 24 hours •Most common cause is uterine atony
Early Postpartum Hemorrhage Risk Factors -(correct answer)-macrosomia -
multiple gestation -polyhydramnios -chorioamnionitis -prolonged labor -use of
Magnesium sulfate -use of oxytocin (Pitocin) Early postpartum hemorrhage
observation -(correct answer)•Unrepaired lacerations of perineum or vaginal
canal •Monitor for continuous trickle of bright red blood •Hematoma's of
perineal area or vaginal -patient complains of unrelieved pain or pressure -
may or may not be able to see -can be caused by forceps or vacuum delivery
Postpartum Medications -(correct answer)•oxytocin (Pitocin) 20 U in 1000ml
of LR or NS •methylergonovine maleate (Methergine) dose: 0.2mg/ q4/ x6 IM
PO 0.2 mg q 4 Check Blood Pressure: DO NOT give if hypertensive Postpartum
medications (prostaglandins) -(correct answer)Prostaglandins: •Misoprostol
(Cytotec)- rectally, sublingual, buccal, or PO x1 •Carboprost Tromethamine
(Hemabate)- IM or intrauterine q15-90 minutes up to 8 doses •Dinoprostone
(Prostin E2)-rectally (contraindicated for hypotension) • •Side effects: nausea,
vomiting and diarrhea Late Postpartum Hemorrhage -(correct answer)•More
, than 24 hrs but less than a week after birth •Common cause- retained
placenta After the first postpartum day the most common cause of uterine
atony is retained placental fragments. The nurse must check for the presence
of fragments in lochia Endocrine Changes -(correct answer)1. Estrogen,
cortisol, placental enzyme insulinase reverse the diabetogenic effects of
pregnancy which means mom will need less insulin (If type I diabetic) 2.
Estrogen and progesterone levels drop markedly and reach rock bottom at 1
week PP which is the main cause of breast engorgement 3. Diuresis - release
extracellular water that is accumulated during pregnancy Pituitary and
Ovarian Function -(correct answer)•Prolactin blood levels rise progressively
throughout pregnancy - In those patients who decide to breast feed they
remain high •First ovulation after delivery varies •1. Ovulation can occur as
early as day 27 PP •2. Non lactating women have a mean time of about 10
weeks •3. Breastfeeding women have a mean time of about 6 months •This is
NOT A FORM OF BIRTH CONTROL Changes in Urinary Elimination -(correct
answer)•Within 12 hours of delivery women begin to lose excess tissue fluid
•Caused by decreased estrogen levels and removal of increased venous
pressure in the lower extremities •Blood loss with normal delivery also aids in
removal of extra fluid •Due to anesthesia and birth trauma to the urethra the
woman may experience a decreased need to void - encourage to void •May
have profuse diaphoresis first 2-3 days. Can void up to 3000mL/day to reduce
volume increase that occurred during pregnancy •Patient should void within 4
hours of delivery •Monitor closely for urine retention if voiding is frequent and
<100mL per voiding UTI -(correct answer)•Increased risk for UTI due to -
decreased urge to void -trauma during birth •Teach signs & symptoms of UTI
to report to PHCP •Teach preventative measures GI changes -(correct
answer)•Appetite changes and mom is typically very hungry after delivery
•May not have BM for 2-3 days due to: 1. decreased muscle tone in intestines
during labor 2. pre labor diarrhea 3. lack of food 4. dehydration 5. fear of pain
•Rectal sphincter tear -may experience some incontinence •Stool softeners
such as Colace given •Instruct on diet to prevent constipation Breast Changes
-(correct answer)•Colostrum is a clear/yellow fluid, first 2-3 days •Milk comes
in at around 72 - 96 hours •Wear supportive bra 24 h Breastfeeding Mothers -
(correct answer)•Feed infant every 2-3 hours •If engorgement occurs feed
baby first then pump or express, but if breasts are too full for latch, may need
to express a little first. •Warm compresses or shower may help •Plugged milk
duct- swollen, tender area -warm compress prior to feeding -feed on affected
side first -pump •Proper latch on important to prevent sore, cracked nipples
