postpartum assessment Flashcards
Within first 24 hrs …
client’s pulse rate begins to drop.
client’s temperature may be slightly elevated.
Vaginal discharge is bloody (lochia rubra) for
3 to 4 days, then it becomes pink or pale brown (lochia serosa).
Lochia alba
After the next 10 to 12 days, it changes to yellowish white
About 1 to 2 weeks after delivery bleeding…
eschar from the placental site sloughs off and bleeding occurs; bleeding is usually self-limited.
Average blood loss for a woman delivering vaginally
200-500mL
Uterus after 5-7 days
It is firm and no longer tender, extending midway between the symphysis and umbilicus.
Ueterus by 2 weeks
It is no longer palpable abdominally.
Uterus 4-6 weeks
Returns to a pre-pregnancy size.
Baby blues symptoms reside by
7-10 days
Postpartum depression occurs
-within the first 12 months after delivery
-does not resolve without intervention
-can affect the mother’s ability to care for herself and her newborn
what physiological maternal changes occur during the postpartum period?
-Urinary output and diaphoresis increase.
-Fundus begins to descend toward the pelvis after 24 hours (involution).
Involution
The fundus begins to descend into the pelvic cavity after 24 hours
Postpartum assessment are done
hourly for the first 2 hours after delivery and then continued every 4 hours during the initial 24 hours postpartum.
BUBBLEHE
Breast
Uterus
Bladder
Bowels and rectum (for hemorrhoids)
Lochia
Extremities/Epistiotomy
Homan’s sign -push foot back looks for thrombosis
Emotional status
the nurse finds the client’s perineal pad saturated with blood and blood soaked into the bed linen under the client’s buttocks. The nurse’s first action is which of the following?
Gently massage the uterine fundus.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
Ask the mother to urinate and empty her bladder.
The nurse is assessing the lochia on a one-day postpartum client. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding:
indicates the presence of infection.
A nurse is instructing a postpartum mother about lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
should never exceed 4 to 8 peri-pads per day
A nurse is providing instructions to a postpartum client after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
three days postpartum.
