lOMoARcPSD|59750855
NSG 3500 Exam 3 - study
Adult Health II (Galen College of Nursing)
, lOMoARcPSD|59750855
NSG 3500 Exam 3
Vaginal Birth Vital Signs Protocol C-section Vital Signs Protocol
Vital signs Vital signs
Fundal assessment Fundal assessment
Lochia Assessment Lochia Assessment
Perineum Assessment Perineum Assessment
Do these assessments at least every 15 min Do these assessments more often than vaginal delivery
“I’m cramping” GOOD uterus is contracting
Fundal Assessment Findings Lochia Assessment Finding
Normal Involution Color: Rubra, Serosa, Alba
Location - Midline, Deviated (abnormal, empty bladder) Amount: scant, Light, Moderate, Heavy
Tone - Firm, Firm with Massage, Boggy (abnormal) Presence of Clots – worry if bigger than quarter size!
Afterpains good! Uterine contracting Should not increase it should gradually decrease
Breast Assessment Findings Perineum Assessment Findings
Inspection of Nipples = Flat, Everted, Inverted
Breast Tissue = Soft, Filling, Firm Pull out pad front to back to avoid infection from butt
Temperature
Color
Inverted nipple: Teach mom to roll nipple to try to get it everted
breastfeeding
BUBBLE-HE BUBBLE-HE
Breasts Lochia
soft, firm (filling with milk– 48-72 hrs.) and engorged (overfilled, Rubra = red = 1-4 days
maybe mom is not breastfeeding?) Serosa = pinkish = 4-9 days
Palpate* also assess nipples Albacans = white and creamy = 10-14 days
Prolactin levels will go up to produce milk Amount? Scant, light, moderate, heavy
Hard to latch baby on engorged breasts hand express to soften Normal: we want scant or light
breast (with spoon) Clots normal – worry if pt has low platelets
Abnormal = quarter size and bigger
Uterus If chorioamnionitis/endometritis
immediately after delivery where would you anticipate the uterus odor/smelly on lochia, pain/tender belly, elevated WBCs and
location? Midway between pubic bone and umbilicus fever
Next hours Encourage them to sit up @ 90 to drain infection
Normal finding: firm uterus and midline @ umbilicus OR massage
to firm Episiotomy/Epidural
A deviated uterus would mean that bladder is full – EMPTY REEDA
“She’s 1 finger below umbilicus” Leaked CSF – from wet tap (Dural puncture)
Abnormal: boggy massage until firm Headache when changing position
NSG 3500 Exam 3 - study
Adult Health II (Galen College of Nursing)
, lOMoARcPSD|59750855
NSG 3500 Exam 3
Vaginal Birth Vital Signs Protocol C-section Vital Signs Protocol
Vital signs Vital signs
Fundal assessment Fundal assessment
Lochia Assessment Lochia Assessment
Perineum Assessment Perineum Assessment
Do these assessments at least every 15 min Do these assessments more often than vaginal delivery
“I’m cramping” GOOD uterus is contracting
Fundal Assessment Findings Lochia Assessment Finding
Normal Involution Color: Rubra, Serosa, Alba
Location - Midline, Deviated (abnormal, empty bladder) Amount: scant, Light, Moderate, Heavy
Tone - Firm, Firm with Massage, Boggy (abnormal) Presence of Clots – worry if bigger than quarter size!
Afterpains good! Uterine contracting Should not increase it should gradually decrease
Breast Assessment Findings Perineum Assessment Findings
Inspection of Nipples = Flat, Everted, Inverted
Breast Tissue = Soft, Filling, Firm Pull out pad front to back to avoid infection from butt
Temperature
Color
Inverted nipple: Teach mom to roll nipple to try to get it everted
breastfeeding
BUBBLE-HE BUBBLE-HE
Breasts Lochia
soft, firm (filling with milk– 48-72 hrs.) and engorged (overfilled, Rubra = red = 1-4 days
maybe mom is not breastfeeding?) Serosa = pinkish = 4-9 days
Palpate* also assess nipples Albacans = white and creamy = 10-14 days
Prolactin levels will go up to produce milk Amount? Scant, light, moderate, heavy
Hard to latch baby on engorged breasts hand express to soften Normal: we want scant or light
breast (with spoon) Clots normal – worry if pt has low platelets
Abnormal = quarter size and bigger
Uterus If chorioamnionitis/endometritis
immediately after delivery where would you anticipate the uterus odor/smelly on lochia, pain/tender belly, elevated WBCs and
location? Midway between pubic bone and umbilicus fever
Next hours Encourage them to sit up @ 90 to drain infection
Normal finding: firm uterus and midline @ umbilicus OR massage
to firm Episiotomy/Epidural
A deviated uterus would mean that bladder is full – EMPTY REEDA
“She’s 1 finger below umbilicus” Leaked CSF – from wet tap (Dural puncture)
Abnormal: boggy massage until firm Headache when changing position
