L&B/Postprocedure/Nursing Interventions

Question 1

Nursing Assessment during the fourth stage (6)

Answer 1

Maternal VSFundusLochiaPerineumUrinary outputMaternal/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) Massageand or2) administer oxytocics as prescribed to maintain uterine tone to prevent hemorrhage

Question 5

Assess perineumNursing 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 bondingNursing Interventions During Fourth Stage

Answer 7

Promote an opportunity for bonding

Question 8

Client educationNursing Interventions During the Fourth Stage

Answer 8

Instruct client to notify nurse of1) increased vaginal bleeding2) Passage of blood clots3) Offer assistance with breastfeeding and provide reassurance

Question 9

BUBBLE-LES

Answer 9

Breast
Uterus/Fundus
Bladder/Voiding/Foley
Bowel
Lochia/Flow
Episiotomy (REEDA)

Lower Leg: Edema, warmth, redness, discomfort
Emotional/Psychological status
Socialcultural/Spiritual

Question 10

REEDA

Answer 10

Redness
Echymosis
Edema
Discharge
Approximation