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Questions and Answers
Which of the following is NOT a sign of infection to assess for in a patient post-surgery?
What should be assessed in a patient after an epidural regarding lower extremities?
Which of the following nursing interventions can help reduce discomfort for a patient?
Which aspect of emotional status may be present after childbirth?
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What is a critical aspect of patient teaching prior to discharge regarding the Rubella vaccine?
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What is the greatest risk for postpartum complications after delivery?
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How often should assessments be conducted during the first hour post delivery?
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What is a normal finding for pulse and blood pressure postpartum?
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What color is expected for lochia during the early postpartum days?
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What should be assessed when examining the breasts postpartum?
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What is an indicator of potential bladder distention after delivery?
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How much time is typical before a patient usually has a stool after delivery?
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What does the fundamental assessment of the uterus postpartum include?
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Study Notes
Postdelivery Assessment
- Highest risk for postpartum complications occurs within the first 24 hours post-delivery.
- Immediate identification and intervention of potential problems are crucial, followed by continuous reassessment.
- Assessment focuses on uterine condition, bleeding amount, bladder function, vital signs, and perineal status.
Assessment Details
- Fundus: Palpate to ensure it is firm and well contracted.
- Bleeding: Monitor drainage on the pad for blood loss assessment.
- Vital Signs: Monitor pulse and blood pressure to evaluate cardiovascular health.
- Perineum: Check for signs of hematoma, lacerations, and edema.
Monitoring Protocols
- Perform assessments every 15 minutes for the first hour post-delivery.
- Measure temperature at the end of the first hour.
- Transfer to the postpartum unit only when the mother is stable.
Admission to Postpartum Unit
- An effective report must occur between labor and delivery (L&D) nurse and postpartum (PP) nurse.
- Prepare the room with necessary equipment such as an IV pole and vital signs monitoring tools.
Postpartum Assessment
- Conduct a complete assessment upon arrival to the postpartum unit including BUBBLE HE (Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy, and Vital Signs).
- Reassess every hour for the first four hours focusing on uterus, lochia, bladder, blood pressure, and pulse for any abnormal findings.
Vital Signs Considerations
- Elevated Temperature: Common in the first 24 hours but could indicate dehydration or infection.
- Bradycardia: May be normal; assess if concerning symptoms arise.
- Tachycardia: Can indicate infection, hemorrhage, pain, or anxiety.
- Blood Pressure Changes: Low BP may suggest orthostatic hypotension or shock; high BP may indicate pregnancy-induced hypertension.
Breasts Assessment
- Monitor for softness, firmness, lumps, colostrum secretion, and possible engorgement.
Uterus Involution
- Fundus is at the level of the umbilicus on the first day, decreasing in height by 1 fingerbreadth daily.
- It should be firm, round, smooth, and positioned midline.
Bladder Function
- Assess bladder distention to prevent complications like uterine atony or UTI.
- If no void occurs within six hours, recatheterization may be necessary.
Bowel Movement
- Check bowel sounds and inquire about gas pains.
- Expect stool passage 2-3 days postpartum; laxatives or stool softeners may be needed.
Lochia Status
- Monitor the amount and color of lochia, with rubra, serosa, and alba being the expected stages.
Episiotomy Care
- Assess for hematomas, ecchymosis, edema, erythema, intact sutures, and signs of infection in the perineal area.
Homan's Sign for Thrombophlebitis
- Check for unilateral swelling, redness, warmth, and pain, especially in C-section mothers who are at higher risk.
Emotional Status
- Expect mood swings and observe for bonding behavior and the ability to care for the infant using Rubin’s phases, en face interaction, and engrossment.
Patient Post Epidural Care
- Assess lower extremities for sensation and movement; maintain bedrest until evaluation is complete.
Post-Cesarean Section Assessment
- Additional focus on incision site, fluid intake, bladder and bowel function, and mobility to prevent orthostatic hypotension and thrombophlebitis.
Documentation of Findings
- Use assessment checklist forms, graphic sheets, and narrative notes for ongoing documentation.
Nursing Diagnoses and Care Plan
- Create a Nursing Care Plan (NCP) based on findings throughout the chapter.
Interventions
- Prioritize prevention of complications, managing discomfort, and assisting with activities of daily living (ADLs) including nutrition, rest, sleep, ambulation, bathing, and Kegel exercises.
Predischarge Considerations
- Rubella vaccine criteria includes checking titer and hypersensitivity to eggs; provide patient education on administration.
- Administer Rho immune globulin (Rhogam) based on criteria.
Discharge Instructions
- Provide care instructions for both mother and infant, schedule the next appointment, and refer for additional support services as necessary.
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Description
This quiz covers essential assessments for nursing care during the postpartum period, highlighting the critical first 24 hours after delivery. Key areas of focus include the condition of the uterus, vital signs, and potential complications. Preparing nurses to identify and intervene promptly is vital for patient safety.
