NUR 106 Maternal Child Nursing

Postpartum Clinical Rotation Quiz

1. Define PIH and discuss the condition, signs and symptoms of both mild and severe
PIH.
PIH is acronym for pregnancy-induced-hypertension. PIH is a complication of some women during
pregnancy, marked by increasing blood pressure, proteinuria, and edema. This complication occurs most
commonly during the third trimester, although it may occur earlier. The actual cause of PIH is unknown,
but the frequency of this condition occurring increases in pregnant adolescents, older women (↑35yrs),
diabetes, and women carrying multiple fetuses. Signs and symptoms of mild PIH is hypertension,
continuous headache, drowsiness, visual disturbances, numbness of the hands and feet, abdominal pain,
nausea, edema. Severe PIH which occurs when the systolic blood pressure is equal or more than 160
mmHg, or the diastolic pressure is 110 mmHg or more. Symptoms may include any and all of the symptoms
listed for mild PIH, women should report any worsening symptoms especially worsening headaches, visual
disturbances confusion or abdominal upset as they may be indicative of a seizure. The HELLP syndrome is
associated with severe PIH, HELLP syndrome is the following laboratory findings; hemolysis, elevated liver
enzymes, and low platelets.
2. Discuss important nursing assessments/care of the prenatal mother with PIH
(both at home and when hospitalized).
Management of the prenatal mothers care with PIH include: reducing physical activity, bedrest, anti-
hypertensive medications such as hydralazine, and anticonvulsant medications the most commonly used
being magnesium sulfate. The prenatal mother should be aware of the worsening signs and symptoms of
PIH including diminished fetal movements. Daily weights may be ordered for the PIH client, as well as
careful monitoring of her blood pressure (usually done every 4-6hrs in hospitalized patients and every 3-4
days in home care). Laboratory testing such as urinalysis to detect proteinuria may also be ordered. Fetal
assessments are also done more often to assess for evidence of fetal compromise, which can be seen by a
reduced fetal kick count as noted by the mother, a nonreactive stress test, reduced amniotic fluid as seen on
ultrasound, and/or a biophysical profile of 6 or less. The only way to cure PIH is delivery of the
baby. PIH women less than 34 weeks gestation are given steroids to accelerate lung maturity in the fetus,
when steroids are given delaying the birth for at least 48 hours is optimal. If the mother or fetus continue to
deteriorate the delivery of the baby, regardless of the fetal age or steroid administration, will be induced to
save the mother. Natural birth is preferred because of the multisystem impairments involved in PIH.
3. Define placenta previa, the signs and symptoms and care of the prenatal mother.
Placenta previa occurs when the placenta is implanted in the lower uterus, resulting in partial or complete
cover of the cervical os. Only about 10% of the placental previas diagnosed in the second trimester remain
previas at term due to placental migration. The risks of placenta previa is more common in women with
previous previas, cesarean sections, abortion (natural, or induced), older women. The risk is also higher for
Asian and African ethnicities. Cigarette smoking and cocaine use are also risk factors for the condition.
Signs and symptoms of placenta previa may or may not occur, if they do occur the most common is the
sudden and painless onset of uterine bleeding. Many cases are diagnosed by ultrasound examination. When
placenta previa is confirmed the interventions done are based on the conditions of the mother and fetus.
Women who are stable are usually allowed to manage their care at home. Home care includes: strict bed
rest (except for going to the bathroom), teaching the mother and care provider (or spouse/family member)
procedures to follow in case bleeding occurs, as well as how to assess fetal kick count and uterine activity
such as cramping, the mother will also usually be advised to avoid sexual intercourse to prevent placental
disruption. Nurses may also make daily phone calls to assess the woman's compliance to the treatment plan
 as well as to address any concerns the woman may have. If the woman is admitted to the hospital for
placenta previa, the care focuses on the bleeding episodes and possible signs of preterm labor. Electronic
fetal monitoring is done to assess fetal heart activity. Mother's who experience hemorrhaging or
hypovolemia are delivered immediately regardless of fetal maturity.

4. Why is the mother with diabetes classified as a high-risk pregnancy? What are
some of the possible effects on the fetus? How is the pregnant diabetic
managed/treated?
Diabetic mothers are considered high-risk because diabetes can adversely affect the woman and her
unborn child. The effects of an abnormal metabolic environment such as ketoacidosis, hypoglycemia and
hyperglycemia increase the risk of spontaneous abortions, fetal malformations and for the woman to
develop preeclampsia which could be life threatening to both the mother and child. Also more common in
the pregnant diabetic are urinary tract infections, hydramnios, premature rupture of membranes,
macrosomia, shoulder dystocia. Due to the increased chance of macrosomia or infant weighing more than
8.8lb the risk for injury during birth for the mother and infant is higher, diabetic mothers with large baby's
are also more likely to have a cesarean section birth and postpartum hemorrhaging. Treatment of the
pregnant diabetic, usually includes treatments involved in management of diabetic symptoms. It is very
important for the diabetic mother to be aware of the risks involved with her pregnancy for herself and her
unborn child. It is also important that the mother understands that controlling her diabetes is of the up
most importance in preventing complications during pregnancy and birth. Control of the effects of diabetes
in pregnant patients consists of assessing the woman's ability to manage her own blood glucose monitoring
and compliant administration of insulin. Due to the high risk of fetal demise and fetal malformations in the
pregnant diabetic it is important for the patient to get all the prenatal care available to her. Laboratory
studies such as triple-marker screenings may be done to identify any possible neural tube defects, such as
anecephely, ultrasound and fetal echocardiography are also performed around 20 weeks gestation to
determine the fetal growth rate and look for any fetal anomalies. Prenatal visits are more frequent in the
diabetic, as well as laboratory tests. Focus of the pregnant diabetics care centers around: maintaining
normal blood glucose levels; facilitate the birth of a healthy baby; avoid accelerated impairment of blood
vessels and other major organs.

5. Describe the different types of lochia and give the expected time frame that each is
observed. What would be abnormal findings related to lochia and what should the
mother do?
There are three types of lochia; lochia rubra, which is almost entirely blood with some decidua and mucous
and is present for the first 3 days after child birth; lochia serosa, is pink tinged to brown in color, this lochia
is composed of serous exudate, erythrocytes, leukocytes and cervical mucous, the color changes due to the
increased amount of leukocytes attracted to the area for healing purposes as well as a decrease in the
amount of blood. Serosa usually lasts from day 4 to 11 after child birth. Lochia alba, is a white, cream
colored discharge composed of leukocytes, decidual cells, epithelial cells, fat, bacteria, and cervical mucous.
This lochia is present usually until the 3rd week after child birth but may persist until the 6th week. The
lochia should be bright red immediately after childbirth and may have some small clots, the woman should
be informed of what is considered normal so that she will know what is not and to know to report any
abnormal findings such as large clots, heavy saturation of a peri-pad in an hour, and/or any foul odor.
Lochia serosa is usually pink or brown or both in color and is decreased in amount, abnormal findings
would be excessive amount of discharge, foul odors, continued or recurrent bleeding. Lochia alba should be
white, cream, or light yellow in color and continuing to decrease in the amount of discharge, the woman
 should report any increase in the amount of discharge, foul odors, or change in appearance of the lochia
(such as a return to serosa or rubra).

6. Describe the process of milk production. List five things the breastfeeding mother
can be taught to help make breastfeeding successful.
The breasts during pregnancy go through a variety of changes, the areola become darker and larger, the
breasts begin to secrete colostrum by the second trimester. During pregnancy the anterior pituitary secretes
high levels of prolactin which is a hormone that causes the breasts to produce milk, however milk
production is prevented by estrogen, progesterone, and human placental lactogen. The milk is produced in
the alveoli of the breast. Breast milk is formulated from materials from the mother's blood stream, such as
amino acids, glucose, lipids, enzymes, leukocytes and other nutrients. After birth the loss of estrogen,
placental lactogen, and progesterone from the placenta results in the increased level of prolactin which
brings about milk production. The suckling of the infant during the first feedings stimulates increasing
levels of prolactin as well as emptying the breasts of colostrum. The hormone oxytocin which is secreted
from the posterior pituitary also increases with nipple stimulation, and it also causes the milk-ejection
reflex also known as the let-down reflex. During a feeding the let-down reflex occurs several times. This
reflex also often occurs when the mother sees, hears, or even thinks about their infants. Oxytocin is also
responsible for uterine contractions that may occur during a feeding, these contractions speed up the
involution of the uterus.
Mothers who have decided to breastfeed may have some problems in the beginning, explaining the process
of milk production may help them to understand why their bodies are changing and the importance of
continuing a healthy diet with added nutrition. If mothers have problems breastfeeding they may benefit in
teaching sessions. teaching sessions may include; different techniques for positioning the infant during
feedings; relaxation techniques to aid in the release of oxytocin which is necessary for the let down reflex
to occur; how to assess her baby's readiness to feed by reading the baby's cues (licking, lip smacking,
rooting, hands to mouth, increased activity and crying); frequency of breastfeeding sessions to prevent
engorgement; proper latching on of the infants mouth to the nipple. If the mother has any concerns be sure
to address them with the proper knowledge, or have someone who is trained as a lactation consultant speak
with them. Many first time mothers are nervous about breastfeeding and may need additional support and
teaching.

7. What types of OB patients, both delivered and undelivered, should be on I&O and
why?
Pregnant women who have HEG may need to have a strict I&O to help prevent hypovolemia or
dehydration.
Women in labor receiving intravenous infusions should be on I&O because the amount of fluids being put
in need to make sure they are being excreted. Women in labor who have had an epidural may not feel the
need to urinate and their bladders may become distended. A full bladder may even cause pain for the
woman after the epidural has been given. Bladder distension also inhibits the descent of the fetus by taking
up space needed for normal descent into the pelvis. After childbirth women are at risk for fluid volume
deficit, due to the body excreting large amounts of urine, as well as bleeding (both normal and abnormal
amounts of blood). Some women also retain fluids which may cause edema in the extremeties and even
pulmonary edema.

8. Define hyperemesis and discuss the treatment and risks to the fetus.
 Hyperemesis is vomiting that is uncontrollable and persistent and usually begins before the 20th week
of pregnancy. Hyperemesis may continue throughout pregnancy and may cause serious consequences to
the mother and her unborn child. It may cause weight loss of 5% or more of the mothers pre-pregnancy
weight , dehydration, ketosis, acid-base imbalances, electrolyte imbalances, metabolic alkalosis, and vitamin
K deficits. Drug treatment for hyperemesis may include: Phenergan, Benadryl, Pepcid, Zantac, Nexium,
Prilosec, Reglan, Zofran, as well as daily vitamins/mineral supplements. If the previous methods do not
control the vomiting it may be necessary for IV fluids and electrolyte replacement, TPN may also be
necessary in a severe case. The incidence of HEG occuring is higher in unmarried white women and
multifetal pregnancy. The worst case scenario can cause malnutrition of the developing fetus which could
result in poor development. If HEg persists into the 2nd or 3rd trimesters it can cause intrauterine growth
restrictions, oligohydraminos, preterm labor, and even fetal malformations due to the intrauterine growth
restrictions.

9. Define episiotomy and the care and treatments needed.

Episiotomy is the intentional incision of the perineum to enlarge the vaginal opening during birth.
Episiotomies may be very painful for women following childbirth so pain relief measures should be
implemented to help in the reduction of discomfort. Cold peri-pads may be used as well as ice packs. Sitz
baths can be given 2-3 times a day, this provides a continuous circulation of cool water to the perineum
which aids in cleansing and reducing pain caused by swelling. The woman should also be instructed not to
sit down fast and to take caution when sitting so not to cause any additional trauma to the perineum.
Perineal care is important after childbirth especially with tearing or episiotomies, the woman should be
instructed on how to cleanse the perineal area, and to pat dry after cleansing, this aids in cleansing, comfort
and prevention of infections. Women with perineal trauma such as episiotomies may also be given
anesthetic sprays or ointments to help alleviate the pain associated with the trauma.

10. Define fundus and describe the process of involution in the postpartum mother.
The fundus is the part of the uterus that is farthest from the cervix, above the openings of the fallopian
tubes. Involution of the uterus is the changes that occur to the uterus from the time following birth to the
time the uterus returns to normal pre-pregnancy size. Contractions immediately following placental
delivery help in controlling bleeding and starting the process of returning the uterus to normal size. During
involution the epithelium of the uterus is being regenerated as well as shedding the superficial dicidual
layer. The assessment of the location of the fundus helps in determining if involution is progressing
properly. Immediately after birth the fundus can be palpated midway between the symphysis pubis and the
umbilicus. 12 hours after birth the fundus rises to the level of the umbilicus or slightly above or below the
umbilicus. From the second day on the fundus should descend 1cm per day and into the pelvic cavity by the
tenth day. The process of involution is usually slower in women who have large babies or multi-fetal
pregnancies. Involution that does not properly progress causes subinvolution which can cause post partum
hemorrhage.

11. Why is the status of a mother's immunity to rubella important? What information
is given to the mother who is given a rubella injection before discharge?
Determining the status of a woman's immunity to rubella in crucial in preventing spontaneous abortions,
and fetal abnormalities. Rubella is commonly a mild disease that only causes fever, general malaise, and a
rash that spreads from the face to the rest of the body. Pregnant women who have never gotten the rubella
 virus or the immunization are at the greatest risk if they get the virus during the first trimester of their
pregnancy. During the first trimester the fetal organs are developing, and if infection occurs during this
time one-third of all pregnancies will end with spontaneous abortion, the remaining pregnancies may
progress but the risks for physical and mental malformations is severely increased. The common fetal
malformations may be; deafness, mental retardation, cardiac defects, and microcephaly. Babies born to
mothers who were infected during the 2nd or even 3rd trimesters shed the virus for many months prior to
the infection and therefore pose a risk of infecting other infants and people. Women who have never been
vaccinated should not be vaccinated for the rubella virus until the immediate postpartum period so that
they will be immune before becoming pregnant again. The women should be told the risks of becoming
pregnant again during the 28 days following the vaccination. Most facilities that give the rubella vaccine
following child birth require that the woman signs a document indicating that they understand the risks to
the fetus if they do become pregnant in the 28 days following the vaccination.

12. Describe how to assess for Homan's sign and what to do if the results are positive.
The Homan's sign is positive if pain or discomfort is felt in the calf following sharp dorsiflexion of the foot,
it is a possible indication of deep vein thrombosis and should be reported immediately to the health care
provider. Homan's sign should be assessed following childbirth and the immediate days after the birth.
Deep vein thrombosis is the leading cause of maternal mortality, and is 5 times higher in a pregnant
woman than in a non pregnant woman. It is believed to be even higher in the immediate postpartum
period. Assessment for DVT during the postpartum period is crucial in preventing maternal demise. To
assess for the Homan's sign the nurse sharply dorsiflexes the foot while supporting the leg under the knee,
if pain or discomfort is felt in the calf the sign is positive and should be reported immediately. Sometimes
the pain associated with a positive Homan's sign has nothing to do with a DVT, but may just be a pulled
muscle, but the positive sign should always be reported to the physician or healthcare provider immediately
so that treatment of the condition can be started immediately.

13. Define engorgement and what a mother can do to relieve this discomfort.
Engorgement occurs when the breast is swollen with milk. Normal engorgement occurs when the milk
"comes in" at the 3rd to 4th day postpartum. This is a result of an accumulation of milk in the breasts,
enlarged lymph glands and increased blood flow. Normal engorgement should not interfere with
breastfeeding, actually breastfeeding helps relieve the symptoms associated with engorgement, such as
pain, swelling, and tenderness. Abnormal engorgement may occur due to milk retention from delayed
feedings, too short or too infrequent feedings. The engorgement from milk retention causes swelling,
hardening, tender, extremely painful breasts along with fever in the engorged areas. This type of
engorgement can make it almost imbearable to breastfeed or even move at times, the infant may not even
be able to latch onto the nipple due to the swelling causing the nipple to become flat.. This is a common
reason mothers stop breastfeeding after being discharged from the hospital. Teaching women who are
breastfeeding the importance of frequent feedings to help prevent engorgement. Women who do get
engorged may find relief using hot and cold packs, as well as massage. Along with breastfeeding, a breast
pump may be used to express the extra milk, if milk is expressed by pumping it can be frozen for future
feedings, such as the mom's first night out following the birth of her child!

14. What is a sitz bath and what are the benefits for the mother?
 A sitz bath circulates cool water on the perineum which cleanses and provides some pain relief associated
with the after effects of childbirth, especially perineal trauma. Sitz baths may be given 3-4 times a day.

15. What are the two types of cesarean section incisions? How is the incision cared for
and what are some of the things mothers are taught about their incision?
The two types of cesarean section incisions are the low transverse incision and the vertical incision. The low
transverse incision is an incision made at the bikini line and is not suitable for emergency cesarean sections
or for a large fetus, this type of incision is usually planned. The vertical incision is used in emergency
situations and is usually more appropriate for obese women and multi-fetal pregnancies. Care of the
incision is extremely important to prevent infections. Staples are the usual method for closing the incision
and are usually removed before discharge. Adhesive strips are applied following the removal of the staples,
the woman may shower as normal, the adhesive strips will gradually detach. The woman should be told
that it is unlikely the incision will come apart. She should also be instructed to not lift heavy objects or to do
any strenuous exercise until she is advised by her physician. Keeping the incision clean and following the
proper dressing changes if needed. The woman should be told to report any signs of infection, such as pain,
discharge, swelling, foul odor or redness of the incision site.

16. What is the significance of a mother's blood type and group after delivery? What is
Rhogam and why and when is it administered to the postpartum mother?
The mother's blood type is important to establish following the birth of her first child to determine her Rh
factor. It is important to determine whether the mother is Rh negative, because a mother who is Rh negative
may produce antibodies affecting further pregnancies. If the mother is Rh negative, the fetus has a positive
blood type and the mother is not already sensitized the administration of Rhogam is necessary. Rhogam
should be given within 72 hours following childbirth to prevent maternal antibodies that would affect any
future pregnancies from forming.