L&B 3/Postprocedure/Nursing Interventions

Question 1

Nursing Assessment during the fourth stage (6)

Answer 1

Maternal VS
Fundus
Lochia
Perineum
Urinary output
Maternal/newborn baby friendly activities

Question 2

Assess maternal VS/How often?

Nursing Interventions During Fourth Stage

Answer 2

Maternal VS q15mins for the first hour and the according to facility protocol

Question 3

Assess fundus and lochia/How often?

Nursing Interventions During Fourth Stage

Answer 3

q15mins for the first hour and the according to facility protocol

Question 4

Assess uterine fundus (2)

Nursing Interventions During Fourth Stage

Answer 4

1) Massage
and or
2) administer oxytocics as prescribed to maintain uterine tone to prevent hemorrhage

Question 5

Assess perineum

Nursing Interventions During Fourth Stage

Answer 5

Provide comfort measures as indicated

Question 6

Assess urine output

Nursing Interventions During Fourth Stage

Answer 6

Encourage voiding to prevent bladder distention

Question 7

Maternal/newborn bonding

Nursing Interventions During Fourth Stage

Answer 7

Promote an opportunity for bonding

Question 8

Client education

Nursing Interventions During the Fourth Stage

Answer 8

Instruct client to notify nurse of

1) increased vaginal bleeding
2) Passage of blood clots
3) Offer assistance with breastfeeding and provide reassurance

Question 9

Lochia?

Answer 9

Vaginal discharge