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Vitamin k given to prevent vitamin k bleeding and

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Vitamin K-Given to prevent vitamin-K bleeding and hemorrhage. Clotting factor.Single intramuscular dose of .5-1 mg at birthCannot make Vit. K until after oral intake; takes about 1 week for baby to produce enough vitamin Kto prevent Vitamin K bleeding.Normal Assessment Findings:Temp: 36.5-37.2 (97-99)Pulse: 110-160Resp: 30-60 (irregular abdominal breathing)BP: Not checkedO2: 95%+Weight: 2500-4500 gm (5 lbs.8 oz- 8 lbs.13 oz) [lose 5-10% first 3-5 days)Length: 45-55 cm (17-21 in).Face: SymmetricalEyes: In line with earsEars: Tags/sinus/position/cartilageNose: PatentMouth: Symmetry with cryPalate: intactGums: Presence/absence of teeth/Epstein’s pearlsUmbilical cord: 3 vesselsHead: Larger than chest (not more than 2 cm, or smaller)Anterior fontanelle: diamond shaped [closes at 18 mo.]Posterior: triangle shaped [closes 8-12 wks]Creases in hands/feetSimian crease [single palmar crease]= DownsPlantar creases=gestational ageMongolian Spots: Bluish black pigments in buttocks/backNevi: Stork bites; blanch when press and fade = hemangiomaErythema Toxicum: normal rashIdentify and describe the key nursing interventions and expected findings for the mother in the postpartumperiod including: lochia type and amount, fundal involution and time frame, appropriate perineal care (ice vs.sitz bath), need for Rhogam and psychological adjustmentsLochia:post-birth uterine dischargeLochia Rubra: Blood and decidual and trophoblastic debrisDuration approx. 3-4 daysLochia Serosa: Old blood, serum, leukocytes, and debrisBegins on approx. day 3 or 4, lasts up to 2 weeks after birthLochia Alba: Leukocytes, decidua, epithelial cells, mucus, serum, and bacteriaContinues 2-6 weeks after birthExcessive bleeding:Saturation of a perineal/sanitary pad within 15 minutes or less.Pooling of blood under the buttocks.
Requires immediate assessment and intervention.Most lochia described as scant, light, moderate, heavyUterus involution: return of uterus to nonpregnant state following birth.2 cm below umbilicus at the end of 3rdstage of laborWithin approx. 12 hours returns to approx. umbilicus (+/- 1 cm)Progresses rapidilyoFundus descends 1-2 cm every 24 hrs.o2 weeks after childbirth uterus lies in true pelvis.Uterus sub-involution: failure of uterus to return to non-pregnant stateCommon causes are retained placental fragments and infection.Teach patient and family about foul-smelling lochia, higher uterus, and more bleeding than usual.Perineal Care: Ice packs for first 24 hoursPeribottleSitz bath (water water soak after 24 hours)Avoid straining for BMUse sitz bath after BMNeed for RhoGAM: Rh negative mothers must be evaluated for need of RhoGAM after deliveryDetermine infant blood type and RhIf infant is Rh positive, mother must receive RhoGAM within 72 hours of delivery to prevent Rhisoimmunization.oSensitization of maternal blood and development of antibodies to Rh positive blood.
oProblem with future pregnancies.

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Term
Fall
Professor
Theresa Bucco
Tags
progesterone, Headaches, asymptomatic

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