Assess post-partum status (same intervals for assessment): fundal position and contractions, conditions of incision and abdominal dressing, maternal neonatal attachment, lochia (color/amount), neonate condition (if applicable); feeding preferences.Assess hourly I&O (IV, urine output) and re-establishment of bowel sounds. Perform pain assessment: evaluate level of anesthesia, medications are given (amount/time/results). Health Promotion and MaintenanceNursing Process: AssessmentApplicationRicci, Ch. 15Concept: ReproductionExemplar: PregnancyFocus: Rh FactorIf the client is Rh-negative, check the Rh status of the newborn. Verify that the woman is Rh-negative and has not been sensitized, that her indirect Coombs test (antibody screen) is negative, and that the newborn is Rh-positive. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process. Administering RhoGAM prevents initial isoimmunization in Rh-negative mothers by destroying fetal erythrocytes in the maternal system before maternal antibodies can develop and maternal memory cells become sensitized. This is a classic passive immunization technique. Protocol for the Rh-negative woman is to receive two doses of Rh immunoglobulin (RhoGAM), one at 28 weeks’ gestation and the second dose within 72 hours after childbirth. The standard dose of Rho(D) immune globulin (RhoGAM) is 300 mcg given intramuscularly, which prevents the development of antibodies for an exposure of up to 15 mL of fetal red blood cells. RhoGam contains actual Rh antibodies produced by people who have become sensitized. It is therefore, a blood product. Each dose contains enough anti-D to suppress the immune response of 15mL of Rh-positive red blood cells. Physiological Integrity: Pharmacological and Parenteral TherapiesNursing Process: InterventionApplicationRicci, Ch. 16
San Antonio College Department of Nursing EducationRNSG 1538 Exam #1 Blueprint Spring 2019 (Student)ObjectivesQuestionNCLEX-RN Client NeedCategoryIntegratedProcessesBloom’sTaxonomyReference Concept: ReproductionExemplar: PregnancyFocus: Parent Newborn Attachment Attachment is the development of strong affection between an infant and a significant other (mother, father, sibling, and caretaker). This attachment is reciprocal; both the significant other and the newborn exhibit attachment behaviors. The attachment relationship formed between the infant and primary caregiver influences the child’s view of the world and future relationships (Sette, Coppola, & Cassibba, 2015). This tie between two people is psychological rather than biologic, and it does notoccur overnight. The process of attachment follows a progressive or developmental course that changes over time. The newborn responds to the significant other by cooing, grasping, smiling, and crying. Nurses can assess for attachment behaviors by observing the interaction between the
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Term
Summer
Professor
McPherson
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