NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
Post Partum Nursing Care
• Begins after delivery of the placenta and ends when the body returns to
pre- pregnancy state (6 weeks)
• Risk:
o Hemorrhage, shock, infection
• Focus of nursing care
o Main goal is to prevent post partum hemorrhage
o Provide comfort measures
o Facilitate parent-newborn bonding
• Physiological and psychological adjustments
Postpartum Hormonal Changes
• Oxytocin- released from pituitary, coordinates and strengthens
uterine contractions
o Breast feeding stimulates the release of oxytocin
o (Oxytocin)Pitocin may be administered postpartum to improve
uterine contractions, prevent excessive bleeding and
hemorrhage
o Uncomfortable uterine cramping is referred to as AFTERPAINS
o Management of Afterpains: motrin, heating pack,
• After delivery of placenta, estrogen, progesterone, and placental
insulinase decrease
o Decreased estrogen
o Decreased progesterone
o Decreased placental insulinase
Post-partum Thermoregulation
• First two hours post partum
• r/t nervous systems response – pressure on pelvis and now no pressure
– nerves going to response – vaso motor changes
• Mom will have chills and shaking
• Epidural
• Shift in fluid between mom and fetus
• Chills and shakes are Normal unless it is happening with a fever( >101
w/in first 24hrs) – thinking mom will have infections
Postpartum Assessment
• B-Breast
o Tenderness, nipple irritation (open for bacteria)
o Soft, no cracking or bleeding
• U- Uterus
o Fundus firm, at or below umbilicus, midline
• B- Bowel
o GI function, bowel sounds, hemorrhoids
[Type text]
, NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
• B- Bladder
o Uterus will not contract and go back to pre-pregnancy size if bladder if
full
o Adequate voiding, non-distended, non-palpable
• L- Lochia
o Color, odor, clots, amount
• E- Episiotomy/laceration
o REEDA (Red, Edema, Ecchymosis, Drainage, Approximated)
• L- Legs for DVT or (H – homin sign)
o Warmth, edema
• E- Emotions
o How is mom doing with the pregnancy
Fundal Assessment
• Fundal height, uterine placement, and consistency
• Fundal height
o Above , below or a level of umbilicus
• Uterine Placement
o Midline or displaced laterally
• Consistency
o Firm or boggy
• Management of boggy fundus
o Massage in circular motion with palm of hand until firm (indicates
hemorrhaging)
o If it doesn’t firm then call physician
o Meds: Pitocin, Cytotech, Metergine, Hemabate
• Midline between symphysis pubis and umbilicus
• 6-12 after birth the fundus come to the level of umbilicus
• Fundus will decrease 1 cm (fingerbreadth) each day
Lochia
• Rubra (1-3 days)
o Dark red
o Few small clots (no larger than a nickel) are common, but large
clots (lemon/plum size) are not normal and contact PCP
• Serosa (4-10 days)
o Pinkish color
• Alba (11 days to 6 weeks)
o White discharge
o More WBC, epithelial, fat cells
• Persistent rubra or return back to rubra indicates subinvolution or PPH –
call doctor
• Volume:
o Heavy – >6 inches in 1 hour; 30-80 mL
[Type text]
, NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
o Moderate – <6 inches in 1 hour; 25-50 mL
o Light – <4 inches of lochia in 1 hour; 10-25 mL
o Scant – < 1 inch of lochia in 1 hour
Cervix, Vagina, and Perineum
• Cervix
o Oss will not close completely, lacerations may lead to infection
• Vagina
o Muscle tone will not go back to normal
• Perineum
o Red, episiotomy/laceration – assess using REEDA
• Management of discomfort
o Ice packs, sitz bath, topical agents (dermoplast, lidocaine spray),
peribottle, Tylenol
• Reduce risk of infection
o Change pads regularly, wash hands, use peribottle, etc
Breasts
• Physiological changes
o Colostrum – “liquid gold”
▪ Thick, creamy, yellow fluid with large amounts of protein,
fat- soluble vitamins, minerals
▪ Antioxidants and high levels of lactoferrin and IgA
▪ Helps protect newborn from disease and illness and helps
pass meconium stool
o Engorgement
▪ Breasts fill with transitional milk
▪ Hard, painful, warm, and appear shiny and taut
▪ Breasts not emptied at feeding, missed or infrequent feedings
• Assessment
o Redness and Tenderness
o Cracked nipples
o Correct LATCH
o Comfortable position
Cardiovascular System and Fluid and Hematologic Status
• Blood loss- 500ml vaginal 1,000 ml C-section
• Increase cardiac output
o Hypovolemic shock not normal occurrence
• Post partum Lab Values:
o Hemoglobin & Hematocrit (decrease)
o WBC (increase)
o Coagulation and fibrinogen factors (increase)
• Diaphoresis and diuresis of excess fluid during third trimester resolve
within 2-3 days post delivery
[Type text]
, NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
o From decrease estrogen
GI System
• Decrease in GI muscle tone and motility post –birth
o Return to normal week 2 post-partum
• Assess for bowel sounds, constipation, hemorrhoids, and appetite.
• Increase fluids 8-10 glasses per day and fiber intake
• Encourage ambulation
• Administer stool softener-Colace
• Enemas/suppositories
Urinary System
• Urinary retention
o Increased capacity, swelling and bruising
o Loss of bladder elasticity and tone or sensation from
trauma, medication or anesthesia
o Distended bladder
o Postpartum diuresis-↑UO begins within 12 hours post delivery
o Assess voiding q 2-3 hours
o Assess for bladder distention
• Straight cath if unable to void or urinary retention
• Increase fluids to prevent fluid loss form delivery and prevent dehydration
• I&O for first few voids after delivery to assess bladder emptying
Musculoskeletal System
• By 6-8 weeks post birth
o Joints return to pre-pregnancy state
o Muscle tone restore-from delivery of placenta and ↓ progesterone
o Diastasis recti separation
• Patient Education
o Simple strengthening exercises
o C-section postpone abdominal exercises until 4 weeks postpartum
o Good body mechanic and proper posture
Immune System
• Review Rubella status
o Titer 1:8 - mom is rubella immune
o < 1:8 – need MMR injection SC and use BC for 28 days
• Review Hepatitis B status
• Review Rh status
o 72 hours
• Review varicella status
• Review tetanus-diphtheria and pertussis vaccine status
[Type text]
GUIDE WITH COMPLETE SOLUTIONS 2023
Post Partum Nursing Care
• Begins after delivery of the placenta and ends when the body returns to
pre- pregnancy state (6 weeks)
• Risk:
o Hemorrhage, shock, infection
• Focus of nursing care
o Main goal is to prevent post partum hemorrhage
o Provide comfort measures
o Facilitate parent-newborn bonding
• Physiological and psychological adjustments
Postpartum Hormonal Changes
• Oxytocin- released from pituitary, coordinates and strengthens
uterine contractions
o Breast feeding stimulates the release of oxytocin
o (Oxytocin)Pitocin may be administered postpartum to improve
uterine contractions, prevent excessive bleeding and
hemorrhage
o Uncomfortable uterine cramping is referred to as AFTERPAINS
o Management of Afterpains: motrin, heating pack,
• After delivery of placenta, estrogen, progesterone, and placental
insulinase decrease
o Decreased estrogen
o Decreased progesterone
o Decreased placental insulinase
Post-partum Thermoregulation
• First two hours post partum
• r/t nervous systems response – pressure on pelvis and now no pressure
– nerves going to response – vaso motor changes
• Mom will have chills and shaking
• Epidural
• Shift in fluid between mom and fetus
• Chills and shakes are Normal unless it is happening with a fever( >101
w/in first 24hrs) – thinking mom will have infections
Postpartum Assessment
• B-Breast
o Tenderness, nipple irritation (open for bacteria)
o Soft, no cracking or bleeding
• U- Uterus
o Fundus firm, at or below umbilicus, midline
• B- Bowel
o GI function, bowel sounds, hemorrhoids
[Type text]
, NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
• B- Bladder
o Uterus will not contract and go back to pre-pregnancy size if bladder if
full
o Adequate voiding, non-distended, non-palpable
• L- Lochia
o Color, odor, clots, amount
• E- Episiotomy/laceration
o REEDA (Red, Edema, Ecchymosis, Drainage, Approximated)
• L- Legs for DVT or (H – homin sign)
o Warmth, edema
• E- Emotions
o How is mom doing with the pregnancy
Fundal Assessment
• Fundal height, uterine placement, and consistency
• Fundal height
o Above , below or a level of umbilicus
• Uterine Placement
o Midline or displaced laterally
• Consistency
o Firm or boggy
• Management of boggy fundus
o Massage in circular motion with palm of hand until firm (indicates
hemorrhaging)
o If it doesn’t firm then call physician
o Meds: Pitocin, Cytotech, Metergine, Hemabate
• Midline between symphysis pubis and umbilicus
• 6-12 after birth the fundus come to the level of umbilicus
• Fundus will decrease 1 cm (fingerbreadth) each day
Lochia
• Rubra (1-3 days)
o Dark red
o Few small clots (no larger than a nickel) are common, but large
clots (lemon/plum size) are not normal and contact PCP
• Serosa (4-10 days)
o Pinkish color
• Alba (11 days to 6 weeks)
o White discharge
o More WBC, epithelial, fat cells
• Persistent rubra or return back to rubra indicates subinvolution or PPH –
call doctor
• Volume:
o Heavy – >6 inches in 1 hour; 30-80 mL
[Type text]
, NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
o Moderate – <6 inches in 1 hour; 25-50 mL
o Light – <4 inches of lochia in 1 hour; 10-25 mL
o Scant – < 1 inch of lochia in 1 hour
Cervix, Vagina, and Perineum
• Cervix
o Oss will not close completely, lacerations may lead to infection
• Vagina
o Muscle tone will not go back to normal
• Perineum
o Red, episiotomy/laceration – assess using REEDA
• Management of discomfort
o Ice packs, sitz bath, topical agents (dermoplast, lidocaine spray),
peribottle, Tylenol
• Reduce risk of infection
o Change pads regularly, wash hands, use peribottle, etc
Breasts
• Physiological changes
o Colostrum – “liquid gold”
▪ Thick, creamy, yellow fluid with large amounts of protein,
fat- soluble vitamins, minerals
▪ Antioxidants and high levels of lactoferrin and IgA
▪ Helps protect newborn from disease and illness and helps
pass meconium stool
o Engorgement
▪ Breasts fill with transitional milk
▪ Hard, painful, warm, and appear shiny and taut
▪ Breasts not emptied at feeding, missed or infrequent feedings
• Assessment
o Redness and Tenderness
o Cracked nipples
o Correct LATCH
o Comfortable position
Cardiovascular System and Fluid and Hematologic Status
• Blood loss- 500ml vaginal 1,000 ml C-section
• Increase cardiac output
o Hypovolemic shock not normal occurrence
• Post partum Lab Values:
o Hemoglobin & Hematocrit (decrease)
o WBC (increase)
o Coagulation and fibrinogen factors (increase)
• Diaphoresis and diuresis of excess fluid during third trimester resolve
within 2-3 days post delivery
[Type text]
, NURS POST PARTUM ADAPTATION EXAM STUDT
GUIDE WITH COMPLETE SOLUTIONS 2023
o From decrease estrogen
GI System
• Decrease in GI muscle tone and motility post –birth
o Return to normal week 2 post-partum
• Assess for bowel sounds, constipation, hemorrhoids, and appetite.
• Increase fluids 8-10 glasses per day and fiber intake
• Encourage ambulation
• Administer stool softener-Colace
• Enemas/suppositories
Urinary System
• Urinary retention
o Increased capacity, swelling and bruising
o Loss of bladder elasticity and tone or sensation from
trauma, medication or anesthesia
o Distended bladder
o Postpartum diuresis-↑UO begins within 12 hours post delivery
o Assess voiding q 2-3 hours
o Assess for bladder distention
• Straight cath if unable to void or urinary retention
• Increase fluids to prevent fluid loss form delivery and prevent dehydration
• I&O for first few voids after delivery to assess bladder emptying
Musculoskeletal System
• By 6-8 weeks post birth
o Joints return to pre-pregnancy state
o Muscle tone restore-from delivery of placenta and ↓ progesterone
o Diastasis recti separation
• Patient Education
o Simple strengthening exercises
o C-section postpone abdominal exercises until 4 weeks postpartum
o Good body mechanic and proper posture
Immune System
• Review Rubella status
o Titer 1:8 - mom is rubella immune
o < 1:8 – need MMR injection SC and use BC for 28 days
• Review Hepatitis B status
• Review Rh status
o 72 hours
• Review varicella status
• Review tetanus-diphtheria and pertussis vaccine status
[Type text]
