PEDS mother/infant postpartum assess

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PEDS mother/infant postpartum assess
2011-05-12 14:14:28
Pediatric postpartum assessment

postpartum assessment mother & infant nsg 314
Show Answers:

  1. Mother assessment strategy
    • General Impression
    • wash hands/glove up
    • VS
    • Head
    • Chest
    • Abdomen & Bladder
    • Fundus
    • Perineum/Lochia
    • Lower Extremities
    • Psyche
    • Education
    • Discharge Plan
  2. Mother General Impression
    • appearance
    • General color
    • non-verbal expression
    • Clear speech
    • CHECK ID
    • pain/effectiveness of tx
    • priority needs/concerns
  3. Mother VS
    • skin Characteristics,
    • color
    • nail bed
    • capillary refill
    • Turger
    • T/BP/P/RR/Pain
  4. Mother Head
    • H/A or VisualChanges
    • Hair clean and “done”
    • Features symmetrical
    • unusual features
    • Eyes are clear
    • Lips/mucus membranes moist
    • Neck full ROM
  5. mother Chest
    • Hx of SOB/cough?
    • Characteristics of Respiration
    • Symmetrical Anatomy
    • Upper Extremities full ROM
    • Heart sounds (pt lift breast PRN)
    • Lung sounds (not through clothing)
    • Breasts/Nipples Density/Skin Integrity, colostrum/milk
  6. Mother Abdomen & Bladder
    • Assess for constipation & voiding
    • Visual appearance
    • Auscultate BS
    • Palpate abdomen/bladder
    • Abd Dressing PRN
  7. Mother Fundus
    • Orientation to umbilicus
    • Midline, L/R to midline, above or below umbilicus in cm
    • (ex U -2 M/L)

    • Consistency: firm, firm w/massage, boggy, full bladder effect assessment
    • Massage fundus prn
  8. Mother Perineum/Lochia
    • Visual appearance of Perineum
    • swelling, redness, bleeding
    • skin/sutures intact
    • Assess amount/characteristic of lochia
    • Assess for hematoma
    • Turns pt to fully examine Perineum
    • Assess for hemorrhoids
    • Epidural insertion site prn
    • lung sounds
    • back of legs color/temp/viens
  9. Mother Lower Extremities
    • Assess color, skin temperature, veins
    • Edema
    • Pedal Pulses/capillary refill
    • Assess for pain when pt dorsiflexes foot,stands or walks
  10. Mother Psyche
    • Assess Mood
    • Assess parent/infant bonding
  11. Mother Education
    • Readiness to learn
    • Prior teaching/understanding
    • Learning priorities for patient/family
  12. Mother Discharge Plan
    • Patient needs/expectation
    • Maternal Plan of care
    • Newborn Plan of care
  13. Newborn Assessment strategy
    • General Impression
    • wash hands/glove up
    • VS
    • Skin FRONT/BACK
    • Head
    • Chest & CV system
    • Abdomen
    • Genitalia
    • Musculo-Skeletal
    • Neuro
    • Safety
    • Discharge Plan
  14. Newborn General Impression

    • Knowledge prenatal/delivery history
    • obvious anomalies
    • skin color
    • tone
    • Posture
    • alertness
  15. Newborn VS
    • Take HR/RR before Temp/physical
    • -lung/heart sounds/murmurs
    • -femoral/brachial pulses
  16. Newborn


    • Deviations: bruising,
    • petechiae, milia, Mongolian
    • spot, port wine stain, rash, meconium staining, “birth marks”, Jaundice

    Newborn rash

    texture: smooth, peeling, dry


    Spinal column/vertebral closing, dimple or tuft of hair along spine (Pilonidal dimple, Nevus pilosis (hairy nevus))

    Planter creases
  17. Newborn Head
    • Shape: Hematoma or Caput?
    • puncture from FSE,
    • Fontanels


    Ears: Skin tags/Hearing test completed?

    Nose: Symmetrical/midline

    Nares: Patent, w/o flaring

    ROM of Neck

    • ROOTING REFLEX (cheek is touched or stroked
    • along the side of the mouth to turn the head toward the stimulated side and
    • begin to suck.)

    Mouth, (usually left until last)Midline, symmetrical lip movement,

    Mucus membranes: color/dryness Palate inspected for cleft
  18. Newborn Chest & CV system

    Respiratory Rate

    Retractions, nasal flaring, Grunting

    Breath sounds

  19. Newborn Abdomen


    Bowel sounds

    Soft to palpate

    Stool pattern

    • Umbilical cord: 2 arteries/
    • 1 vein/Clamp?
  20. Newborn Musculo-Skeletal




    Symmetry – brachial plexus?


    Fused digits

    symmetry of gluteal folds

    Clubbing of feet
  21. Newborn Genitalia
    Normal for GA


    Testes (male)

    Urethral meatus (male)

    Hydrocele (male)
  22. Newborn Neuro

    • Moro: elicited sudden loud noise or raising the head slightly and allowing it to drop. response consists of flexion of the legs, an embracing posture of the
    • arms, and usually a brief cry.

    Wink: automatic closure of the eyelids inresponse to an appropriate stimulus.


    • Grasp: stroking the palm or sole with the
    • result that the fingers or toes flex in a grasping motion

    Babinski: dorsiflexion of the big toe with extension and fanning of the other toes elicited by firmly stroking the lateral aspect of the sole of the foot

    Plantar: firmly stroking the outer surface of the sole from heel to toes, characterized by flexion of the toes

  23. Newborn Safety
    ID Band

    Security Disc

    Bulb syringe in crib

    “Back to sleep”

  24. Newborn Discharge Plan
    Maternal/Family readiness to learn