A postpartum assessment is performed immediately following delivery.
What is done? - ANSWER Full assessment with all VS, then HR and
BP q 15min for 1 hr.
Your patient came into your unit from labour and delivery one hour ago.
She calls you into her room and her peri pad is soaked in blood and
overflowing into the bed pad. What is your first step? - ANSWER Ask
the pt if she has voided since delivery and see if her fundus is deviated
to the right and above the umbilicus. Boggy? Massage.
Acronym for postpartum assessment - ANSWER Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy
Emotional state
Your day 0 post partum pt has a temp of 100.2F. Your first action is...? -
ANSWER Chart the finding. No problem.
A pt calls, states she had a baby two weeks ago and had nearly stopped
bleeding red blood, but today she had bright red blood on her pass
again. What is your best response? - ANSWER Sit down, feet up. Too
much activity will cause flow to increase.
Dependent
,(taking in) - ANSWER Concern for self - eat, sleep, get rid of pain; first
stage after having a baby. May last up to 48hrs. Exhausted, hungry,
pain, in hospital gown, wiped out.
Dependent - independent (taking hold) - ANSWER Beginning to adapt
to rule adjustment, participate in care. 24-72hrs after birth. May have
showered, makeup, own nightie.
-this is when teaching begins
Independent
(letting go) - ANSWER Adjusting to new role. Occurs at home.
Incorporating baby into routine.
Engorgement - ANSWER Rock hard breasts - self limited. 48hrs. If
nursing, nurse frequently. Q 2hr.
If bottle feeding, use ice packs, tight bra, cabbage leaves
Colostrum - ANSWER Yellow, first milk, laxative effect, high in
antibodies
What is hind milk - ANSWER Fattier milk at the end of breast feeding
Let down reflex - ANSWER Breasts- pins and needles, breasts leak
Homan's sign - ANSWER Flex foot - release is painful, check distal
pulses, color, warmth
Involution - ANSWER Return of reproduction to non pregnancy state -
6 weeks
Sub-involution - ANSWER Slower than normal return to prepregnancy
state
The nurse assesses a swollen ecchymosed are to the right of an
episiotomy on a primiparous client 6 hrs after a vaginal delivery. What
can you do? - ANSWER Apply an ice pack to the perineal area.
,3 hrs post partum, a primiparous clients fundus is firm and midline. On
perineal inspection, the nurse observes a small, constant trickle of blood.
What should the nurse assess? - ANSWER Perineal laceration
On the first day post partum, the primiparous client reports perineal pain
5/10 that was unrelieved by ibuprofen 800mg given 2 hrs ago. What
should the nurse assess next? - ANSWER Perineal hematoma
A postpartum client delivered 6 hours ago w/o anesthesia and just
voided 100 mL. The nurse palpated the fundus two fingerbreadths above
the umbilicus and off to the rt side. Firm. What should the nurse do? -
ANSWER Catheterize the pt
The nurse is caring for a primipara who delivered her baby yesterday
and had chosen to breast feed her neonate. Which finding would be
unusual? A) milk production b) diaphoresis c) constipation d) diuresis -
ANSWER A. Milk production. Usually comes on the 3rd day.
A multigravida pt delivered vaginally 2 hrs ago. A family member notifies
the nurse that the client is pale and shaky. What are the priority
assessments? - ANSWER Feel for fundus
Assess lochia
What are the first colors a baby can see? - ANSWER Red
White
Black
Viability - ANSWER At stage where baby could live on its own outside
of uterus. About 24 wks.
Peurperium - ANSWER Postpartum
Peurperal infection - ANSWER Postpartum infection
A woman who delivered yesterday pts her light on because she is
worried she may have an infection because she is diaphoretic. What is
going on? - ANSWER Within 12 hrs pp women begin to lose the
, excess water weight from a decrease in estrogen. Diuesis - excessive
sweating and urine output
When does engorgement occur? - ANSWER Day 4 in both
breastfeeding or not.
What would make a pp woman susceptible to orthostatic hypotension -
ANSWER Hypovolema from hemorrhage
Oxytocic meds
preeclampsia
Why does hct go up after birth even though blood was lost - ANSWER
Drops for 3-4 days then begins to increase. Normal at 8 weeks pp
May be lower than normal if blood loss was increased or if hypovolemia
of pregnancy was less than normal
What is a normal wbc count for a mother after labor?
Why do the values go up?
What else could this indicates? - ANSWER 20-25000
Preterm newborn - ANSWER Before 37 wks
Immaturity of body systems
Resp,low temp, poor suck, gu/gi dec, thin, testes haven't descended,
narrow labia
Monitor q2hr
Maintain airway, o2 and humidity
Post term - ANSWER After 42 wks
Hypoglycemia, lg, dry skin like parchment, long fingernails, scalp hair
meconium staining on nails and umbilical
Simulation, monitor for meconium aspiratiin
What is the 4th stage of labor? - ANSWER 1-2 hrs after placenta
delivery, tone of uterus is reestablished, expels remaining contents, best
feeding stimulates oxytocin
What is done? - ANSWER Full assessment with all VS, then HR and
BP q 15min for 1 hr.
Your patient came into your unit from labour and delivery one hour ago.
She calls you into her room and her peri pad is soaked in blood and
overflowing into the bed pad. What is your first step? - ANSWER Ask
the pt if she has voided since delivery and see if her fundus is deviated
to the right and above the umbilicus. Boggy? Massage.
Acronym for postpartum assessment - ANSWER Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy
Emotional state
Your day 0 post partum pt has a temp of 100.2F. Your first action is...? -
ANSWER Chart the finding. No problem.
A pt calls, states she had a baby two weeks ago and had nearly stopped
bleeding red blood, but today she had bright red blood on her pass
again. What is your best response? - ANSWER Sit down, feet up. Too
much activity will cause flow to increase.
Dependent
,(taking in) - ANSWER Concern for self - eat, sleep, get rid of pain; first
stage after having a baby. May last up to 48hrs. Exhausted, hungry,
pain, in hospital gown, wiped out.
Dependent - independent (taking hold) - ANSWER Beginning to adapt
to rule adjustment, participate in care. 24-72hrs after birth. May have
showered, makeup, own nightie.
-this is when teaching begins
Independent
(letting go) - ANSWER Adjusting to new role. Occurs at home.
Incorporating baby into routine.
Engorgement - ANSWER Rock hard breasts - self limited. 48hrs. If
nursing, nurse frequently. Q 2hr.
If bottle feeding, use ice packs, tight bra, cabbage leaves
Colostrum - ANSWER Yellow, first milk, laxative effect, high in
antibodies
What is hind milk - ANSWER Fattier milk at the end of breast feeding
Let down reflex - ANSWER Breasts- pins and needles, breasts leak
Homan's sign - ANSWER Flex foot - release is painful, check distal
pulses, color, warmth
Involution - ANSWER Return of reproduction to non pregnancy state -
6 weeks
Sub-involution - ANSWER Slower than normal return to prepregnancy
state
The nurse assesses a swollen ecchymosed are to the right of an
episiotomy on a primiparous client 6 hrs after a vaginal delivery. What
can you do? - ANSWER Apply an ice pack to the perineal area.
,3 hrs post partum, a primiparous clients fundus is firm and midline. On
perineal inspection, the nurse observes a small, constant trickle of blood.
What should the nurse assess? - ANSWER Perineal laceration
On the first day post partum, the primiparous client reports perineal pain
5/10 that was unrelieved by ibuprofen 800mg given 2 hrs ago. What
should the nurse assess next? - ANSWER Perineal hematoma
A postpartum client delivered 6 hours ago w/o anesthesia and just
voided 100 mL. The nurse palpated the fundus two fingerbreadths above
the umbilicus and off to the rt side. Firm. What should the nurse do? -
ANSWER Catheterize the pt
The nurse is caring for a primipara who delivered her baby yesterday
and had chosen to breast feed her neonate. Which finding would be
unusual? A) milk production b) diaphoresis c) constipation d) diuresis -
ANSWER A. Milk production. Usually comes on the 3rd day.
A multigravida pt delivered vaginally 2 hrs ago. A family member notifies
the nurse that the client is pale and shaky. What are the priority
assessments? - ANSWER Feel for fundus
Assess lochia
What are the first colors a baby can see? - ANSWER Red
White
Black
Viability - ANSWER At stage where baby could live on its own outside
of uterus. About 24 wks.
Peurperium - ANSWER Postpartum
Peurperal infection - ANSWER Postpartum infection
A woman who delivered yesterday pts her light on because she is
worried she may have an infection because she is diaphoretic. What is
going on? - ANSWER Within 12 hrs pp women begin to lose the
, excess water weight from a decrease in estrogen. Diuesis - excessive
sweating and urine output
When does engorgement occur? - ANSWER Day 4 in both
breastfeeding or not.
What would make a pp woman susceptible to orthostatic hypotension -
ANSWER Hypovolema from hemorrhage
Oxytocic meds
preeclampsia
Why does hct go up after birth even though blood was lost - ANSWER
Drops for 3-4 days then begins to increase. Normal at 8 weeks pp
May be lower than normal if blood loss was increased or if hypovolemia
of pregnancy was less than normal
What is a normal wbc count for a mother after labor?
Why do the values go up?
What else could this indicates? - ANSWER 20-25000
Preterm newborn - ANSWER Before 37 wks
Immaturity of body systems
Resp,low temp, poor suck, gu/gi dec, thin, testes haven't descended,
narrow labia
Monitor q2hr
Maintain airway, o2 and humidity
Post term - ANSWER After 42 wks
Hypoglycemia, lg, dry skin like parchment, long fingernails, scalp hair
meconium staining on nails and umbilical
Simulation, monitor for meconium aspiratiin
What is the 4th stage of labor? - ANSWER 1-2 hrs after placenta
delivery, tone of uterus is reestablished, expels remaining contents, best
feeding stimulates oxytocin
