Postpartum Maternal Nursing Assessment Quiz

Postpartum Maternal Nursing Assessment

• BUBBLES-HEB is an acronym used to denote the components of the postpartum maternal nursing assessment.
• It aids nurses in remembering the components of the assessment.
• B-Breast: Assess size, shape, firmness, and redness.
• U-Uterus: Examine fundus, fundal height, midline position, and deviations.
• B-Bowels: Evaluate bowel sounds and assess for hemorrhoids.
• B-Bladder: Note voiding pattern.
• L-Lochia: Assess type, amount, color, and odor.
• S-Skin: Check for episiotomy complications (redness, edema, ecchymosis, discharge).
• E-Emotional status: Observe for emotional changes like blues, depression, or psychosis..
• H-Homan’s sign: Assess for deep vein thrombosis (DVT)
• B- Bonding: Evaluate parent-infant interactions.

Breast Assessment

• Inspect breasts for redness and engorgement.
• Palpate breasts to determine if they are soft, filling, warm, engorged, or tender.
• Teach mothers to promote milk production and let-down.
• Provide methods to prevent and treat engorgement.
• Advise mothers on proper bra use.
• If not breastfeeding, do not palpate or assess nipples.
• Assess for abnormal findings like redness, heat, pain, cracked/fissured nipples, inverted nipples, palpable masses, painful bleeding, bruising, or blisters.

Uterus Assessment

• Gently place the nondominant hand on the lower uterine segment, above the symphysis pubis.
• Use the dominant hand to palpate the fundus.
• Determine uterine firmness, height of the fundus, position in relation to the midline of the abdomen.
• Correlate fundal location with expected descent (1 cm per day post partum).
• Inspect for any complications (e.g., in incision from c-section, cesarean delivery, or tubal ligation): redness, edema, ecchymosis, discharge, approximation of skin edges..
• Uterus undergoes involution through the process of cell reduction and autolysis.

Uterus Continued

• After delivery, the fundus is located midline, at the level of the umbilicus, and is firm.
• On Day 1, the fundus is approximately one finger's breadth below the umbilicus.
• The fundus descends by one finger's breadth each day until day 10 when it is no longer palpable. This is now behind the symphysis pubis.
• If, after 6 weeks, the uterus is midway between the umbilicus and symphysis pubis, this is abnormal; suggesting something is left inside.
• Assess uterine tone (should be firm), support lower portion one-hand to palpate the fundus with the other hand, avoid overmassaging if boggy.

Sub-Involution or Postpartum Hemorrhage

• Uterus fails to return to original size.
• Causes include retained placental fragments.
• Delayed uterine involution can result from multiple fetuses, hydramnios, exhaustion from prolonged/difficult labor, grand multiparity, or excessive analgesia.
• Physiologic effects of excessive analgesia may affect contraction if retained placenta or membranes are present.

Bowel Assessment

• Assess for flatus passage.
• Check for distension signs.
• Auscultate bowel sounds in all four quadrants, especially in postoperative clients.
• Bowel movements typically occur 2-3 days after vaginal delivery.
• Possible delays due to pain, lack of food, dehydration, soreness from lacerations or hemorrhoids.
• Stool softeners may help with passage.

Bladder Assessment

• Assess for bladder emptying within 6 to 8 hours post-delivery..
• Look for signs like frequency, burning, or urgency— potential urinary tract infection.
• Evaluate ability to empty the bladder completely.
• Palpate for bladder distension if unable to void; incomplete emptying needs attention.

Lochia Assessment

• Vaginal discharge after delivery consisting of blood from the placental site, mucus, and decidua.
• Typically has an alkaline reaction and a non-offensive odor.
• Inspect type, quantity, amount, and odor of lochia.
• Correlate findings with expected characteristics of bleeding.
• Cesarean-delivered women may have less lochia.

Lochia Continued

• Rubra: Dark red, lasts 1-4 days.

• Serosa: Pinkish to brownish, lasts 4-10 days.

• Alba: White, lasts 10-28 days.

• Scant: Less than 2.5 cm (1 inch) stain.

• Light: 2.5 to 10 cm (1 to 4 inch) stain.

• Moderate: 10 to 15 cm (4 to 6 inch) stain.

• Heavy: Saturated in 1 hour.

Episiotomy Assessment

• Inspect the perineum for REEDA (redness, edema, ecchymosis, drainage, approximation):
• Inspect for any hemorrhoids
• Cold or ice packs: provides vasoconstriction, reduces edema, discomfort, and provides anesthetic effect
• Dry-heat with peri-lamp to perineum ( 20 inches, 20 mins 3x a day).
• Moist heat with sitz bath ( 38-42 C˚, 2x a day or more).

Episiotomy Healing Evaluation

• Redness: Infection or hematoma
• Edema: Excessive Bruising → vaginal trauma
• Discharge/Drainage: Assess according to the expected Lochia pattern
• Approximation: Check if episiotomy lines are well approximated

Skin Assessment

• Marked diaphoresis during the first 5 days post-delivery (waste excretion)
• Chloasma and linea negra fade.
• Striae gravidarum (stretch marks) become silvery streaks on thighs, lower abdomen, and breasts
• Diastasis Recti Abdominis (midline separation): some persistence is possible.

Homan's Sign

• Homan’s sign, indicative of deep vein thrombosis (DVT).
• Negative Homan’s sign: no pain.
• Positive Homan’s sign: pain → report to healthcare provider immediately. Perform by pressing on the knee while patient performs foot flexion.

Preventing DVT

• Dangle at bed's edge within 6 hours post-delivery.
• Stand up in bed frequently within 8 hours.
• Encourage early ambulation (independent walking when ready).

Emotional Status

• The immediate postpartum period can be an emotional roller coaster
• Mothers are often exhausted and need rest to restore health
• Mothers may wish to meet their rest and nutritional needs.
• Mothers may use this time to express their feelings of labor and delivery.

Instruction and Guidance

• Self care: Measure general health (perineal care, breast care, care during engorgement), gradual return to daily activities.
• Baby Care: Breastfeeding, baby bathing, dressing, check-ups, immunization, diaper rash prevention/treatment.
• Self in relation to others: Encourage sibling relationships, husband involvement, family planning, resumption of sex 6 weeks post partum.

Taking in Phase

• May begin with a refreshing sleep.
• New mothers during this period, commonly passive, dependent behaviors.
• Spend time touching or interacting with the baby.
• May notice newborns, and their physical traits.

Taking Hold Phase

• Usually begins on the 2nd or 3rd day postpartum, lasting weeks.
• Mothers begin to initiate actions and take on greater independence.
• May require explanations and reassurance of ability to care for the baby..
• Growing concern extends to family members

Letting Go Phase

• Starts towards the end of the first week, and continues.
• Mothers re-establish relationships with family/partner.
• Mothers takes on responsibilities and care for the newborn independently.

Comparing Blues, Depression, and Psychosis

• Postpartum Blues: Hormonal changes, typically lasting up to two weeks, with symptoms like mood swings, anxiety, sadness, overwhelm, crying, and reduced concentration.
• Postpartum Depression: A severe form where mothers are unable to care for themselves or their baby. Symptoms include depressed mood, excessive crying, withdrawal, appetite changes, sleep disturbances, extreme irritability, feelings of hopelessness, worthlessness, self-harm thoughts, and suicidal ideation.
• Postpartum Psychosis: A serious condition requiring immediate intervention. Symptoms include confusion, obsessive thoughts about baby, hallucinations, sleep problems, increased energy, paranoia, harming self or baby.

Bonding

• Describe how parents interact with the infant.
• “Claiming” is identifying ways baby acts like family members.
• "Identification" is establishing a unique nature of the baby.
• Promote bonding early: encourage eye contact, touching, stroking, and cuddling to give positive feedback; allow breastfeeding.

Test your knowledge on the BUBBLES-HEB framework of postpartum maternal nursing assessments. This quiz covers the key components that nurses should evaluate in postpartum patients, including breast, uterus, and emotional status. Enhance your nursing skills with this focused assessment quiz.