week 2 Postpartum Assessment (lab day 4)

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week 2 Postpartum Assessment (lab day 4)
2010-01-31 11:02:17
nvcc test1 unit1 nurs102

Postpartum Assessment
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  1. What is the BUBBLE mnemonic?
    • B = breast - should be soft, engorged, colostrom
    • U = uterus - should be firm, sometimes boggy though
    • B = bladder - should be urinating
    • B = bowel - BM's not normal the first few days postpartum
    • L = lochia - dark, cerosa, moderate to heavy
    • E = episiotomy (intact, swollen, bruised)/extremities/education/emotional
  2. What vitals will the nurse obtain in the postpartum woman?
    • pulse/cardiac
    • respirations
    • GI
    • GU
    • Neuro - headache may be s/s of preeclampsia, epidural would cause decreased mobility
    • skin - rashes, incision
    • 5th vital sign - pain
  3. describe what to expect in the postpartum woman's breast assessment
    • size, shape, symmetry, no lumps
    • soft, filling, firm
    • condition of nipples/areola intact
    • bottle feed vs. breast feed - this is a good time to teach about breastfeeding or prevention of engorgement if applicable
  4. true or false... improper latching can cause sore nipples
  5. true or false... the breastfed baby feeds every 4-5 hours
    false, the baby should feed every 2 - 3 hours
  6. true or false... the non-breastfeeding mother should take hot showers
    false, avoid manually expressing milk, hot showers will cause this, also wear support bra
  7. What do we assess for in the uterine assessment?
    • fundal height and tone - must be firm and midline (of the umbilicus) or problems can occur
    • position in relation to umbilicus is midline
    • consistency - firm is desired, may be boggy
    • if the fundus is is above or below the umbilicus and to the right it means a full bladder
  8. What would indicate a full bladder in the postpartum assessment?
    the fundus is not midline of the umbilicus, it is to the right - this would indicate a full bladder. have the woman void.
  9. Describe the fundal check
    • explain the procedure to the mother
    • mother supine, knees flexed
    • non-dominant hand above symphysis pubis (prevents any downward displacement; prolapse or inversion)
    • other hand to feel for uterine fundus: start with flat part of fingers
    • assess tone, position and observe perineum for blood flow and clots
    • gently massage boggy fundus until uterus returns to firm
    • if the fundus is boggy, get the nursing instructor/primary nurse
  10. true or false... the fundus should be at the pubis by day 9
  11. How do we assess lochia?
    • saturated pads are counted
    • assess color, amount and any clots
    • assess clots, size and consistency
    • lochia rubra should be moderate and no clots
    • color of lochia should be rubra to serosa 4-5 days, later alba (white discharge)
    • odor is fleshy and musty
  12. if the fundus is firm but blood still trickles,what could this mean?
    could be a tear
  13. vaginal bleeding will continue in the postpartum woman for aprox. _______ weeks
    4 to 6 weeks
  14. true or false... it's okay for the postpartum woman to do strenuous excercise
    false, this could cause bleeding
  15. what is lochia rubra?
    bloody, not bright, dark, few clots
  16. what is abnormal lochia?
    large clots, pad saturation, foul odor, excessive amounts, red bleeding
  17. describe the day's progression of lochia
    • day 4: pinkish
    • day 10: serosa
    • day 11: white cream color, not a yeast infection
    • day 11-21 days: alba (small amounts of yellowy, creamy color) not a yeast infection
  18. true or false... alba signifies a yeast infection
  19. how do we assess the bladder?
    • nonpalpable bladder
    • assess amount, frequency, and difficulty initiating voids
    • 300 - 400 mls per void
    • clear, yellow urine
    • measure with hat in toilet

    if bladder is distended you will have to straight cath to clear it out
  20. true or false... a full bladder interferes with contractions and displaces the uterus
  21. how to provide bladder care to the postpartum woman
    • medicate for pain
    • use running water
    • peri bottle
    • early ambulation
    • (straight cath if unable to void)
  22. true or false... the bladder is edematous and hypotonic due to labor
  23. true or false... profuse diuresis is normal after birth
    true, > 3000 mL/day occurs 24 - 48 hours after birth
  24. list some problems with bladder in the postpartum woman
    • 1. urinary distention
    • 2. incomplete emptying
    • 3. retention with overflow
  25. Describe the normal bowel assessment
    • soft abdomen
    • + bowel sounds
    • + flatus
    • check for hemorrhoids
    • check date of last BM
  26. decreased bowel sounds could indicate what?
    increased constipation
  27. how can we decrease inflammation on the postpartum woman's bowel area?
  28. How does the nurse assess the perineum?
    • Have mother lay on her side
    • lift up her upper buttock/leg
    • check episiotomy, laceration or for hemorrhoids
    • use a penlight - a continuous trickle of blood could indicate a tear
    • evaluate for redness, edema, ecchymosis, discharge, approximation (REEDA)

    keep mother comfortable, pain free. use ice packs for 20 minutes at a time, pain meds
  29. define ecchymosis
  30. define REEDA
    • Redness
    • Edema
    • Ecchymosis
    • Discharge
    • Approximation (bringing together especially the cut edges of tissue)
  31. an episiotomy incision can be ______, ______, or ______
    • midline
    • RML - right mediolateral
    • LML - left mediolateral
  32. What do we assess the extremities for in the postpartum woman?
    • assess lower legs for redness, swelling or warmth
    • bilateral pedal edema
    • pedal pulses
    • 1+ to 2+ deep tendon reflexes
  33. why do we assess for deep tendon reflexes in the postpartum woman?
    because it could be s/s of pregnancy induced hypertension
  34. what is hyperreflexia?
    overactive or overresponsive reflexes. Examples of this can include twitching or spastic tendencies. could indicate the cerebral area has some irritability or interupted pathways as related to a seizure.
  35. Match the following:
    A. 1st degree laceration 1. to the anal sphincter
    B. 2nd degree 2. skin almost to muscle, ice packs for 20 mins
    C. 3rd degree 3. to the rectal mucosa
    D. 4th degree 4. through the anal sphincter
    • A2
    • B1
    • C4
    • D3
  36. Assessing the mother education and emotional status
    • assess her emotional status
    • get her comfy and pain free
    • assess fatigue/sleep patterns
    • assess pain leel
    • assess mother/infant attachment behaviors
    • assess teaching needs
  37. what is "taking in" vs. "taking hold"?
    • taking in is when the mother lets everyone around her do their stuff, she is a bystander
    • taking hold is when the mother begins doing things on her own, she is active participant
  38. during immediate postpartum, vital signs should be taken
    A. q3 hours
    B. q1 hour
    C. q30 mins
    D. q15 mins
    D. q15 minutes for the first hour
    (this multiple choice question has been scrambled)
  39. true or false... you will see a generalized shaking and chattering of the teeth immediate postpartum?
  40. how often should you check the fundus and lochia immediately postpartum?
    • q 15 minutes for the first hour after delivery
    • q 30 minutes for the next 2 to 3 hours
    • q hour for the next 4 hours
    • q 4 hours for the rest of the first postpartum day
    • and then q 8 hours until the patient is discharged
  41. true or false... Every 24 hours the fundus should be 1 cm (or 1 finger breadth) below the umbilicus
  42. don't forget patient history as part of the postpartum assessment!
    ask the mother about it, don't just rely on medical records. this is a good way to find out her emotional state about pregnancy and childbirth
  43. this vaginal discharge is similar to menstrual flow and consists of blood, fragments of the decidua, white blood cells, mucus and some bacteria
  44. When assessing lochia, what do we look for?
    • amount - increases with activity - such as getting oob, lifting heavy objects, walking upstairs, should be present for at least 3 weeks postpartum)
    • color - rubra, serosa or alba
    • odor - similar to menstrual flow, should not be foul
  45. true or false... it is normal for the patient to saturate a peri pad in less than an hour
    false, this is not normal and should be reported