Postpartum Assessment
A client is 12 hours post-vaginal birth. Findings: fundus firm, midline, at the umbilicus; moderate lochia rubra with a few small clots; temperature 100.2°F (37.9°C); pulse 62/min. How should the nurse interpret these findings?
Expected findings. Continue routine postpartum assessments.
On postpartum day 4, a client is tearful and irritable and says she doesn't know why she keeps crying. She is caring for her newborn well. What is this, and what should the nurse tell her?
Baby blues. Reassure her it's common, encourage rest and sleep, and teach her to call if it lasts beyond 2 weeks or gets worse.
A 1-hour-old newborn has HR 152, RR 48 and irregular with a 10-second pause in breathing, and axillary temp 97.9°F (36.6°C). How should the nurse interpret these findings?
Normal findings for a newborn in transition.
At discharge, the parents buckle their newborn into a rear-facing car seat with the straps at shoulder level and the chest clip over the belly. What should the nurse correct?
Move the chest clip up to armpit level.
A client at 32 weeks has painless, bright red vaginal bleeding, and ultrasound confirms placenta previa. Which common assessment must the nurse avoid?
A digital vaginal (cervical) exam.
Two hours after birth, the fundus is firm, 2 cm above the umbilicus, and deviated to the right. Lochia is moderate. What should the nurse do first?
Help the client empty her bladder (void or catheterize).
Six hours after birth, a client keeps retelling her labor story, asks the nurse to hand her things within reach, and isn't interested in the newborn bath demo. Which maternal adjustment phase is this, and what should the nurse do?
The taking-in phase. Listen to her birth story,
A newborn's bassinet is placed right next to a cold exterior window. Which type of heat loss is this baby at risk for?
Radiation
A parent asks why the newborn needs a vitamin K injection. What is the nurse's best explanation?
A newborn's gut doesn't yet have the bacteria that make vitamin K, so the shot prevents serious bleeding.
After a fall at 33 weeks, a client has knife-like abdominal pain, dark red bleeding, and a rigid, board-like uterus. What condition does this suggest, and how does it differ from previa?
Placental abruption. Abruption is painful with dark red bleeding and a tender uterus; previa is painless with bright red bleeding and a soft uterus.
On postpartum day 14, a client calls to report that her bleeding has turned bright red again after it had been pinkish-brown for a week. What complication does this suggest?
Subinvolution, possibly from retained placental fragments.
rationale:
Lochia should progress rubra → serosa → alba and never reverse. Rubra coming back after serosa means the uterus is not involuting as expected and needs follow-up.
A client is Rh-negative, her newborn is Rh-positive, and her indirect Coombs test is negative. What should the nurse do?
Give the mother Rh immune globulin (RhoGAM) within 72 hours of birth.
A 2-hour-old newborn's temp is 96.8°F (36.0°C). Name two complications the nurse should anticipate from this cold stress, and explain why.
Hypoglycemia and respiratory distress (also metabolic acidosis and jaundice).
A breastfeeding client on day 4 with engorgement says, "I'll skip feeding on the swollen side until it goes down." Does she need more teaching, and what should she do?
Yes. She should feed or empty frequently on both sides, use warm compresses or a shower before feeds, and cold compresses between feeds.
A client on IV magnesium sulfate has RR 10, absent patellar reflexes, and urine output of 20 mL/hr. What should the nurse do first, and what is the antidote?
Stop the magnesium infusion. The antidote is calcium gluconate.
One hour after a forceps-assisted birth with a 2nd-degree laceration, the fundus is firm and midline with moderate lochia. The client reports intense rectal pressure and pain her analgesic isn't relieving. Pulse has climbed from 78 to 108/min. What complication should the nurse suspect?
A vaginal or perineal hematoma (concealed bleeding).
Four clients gave birth vaginally 1–2 hours ago. Which one should the nurse see first?
The G4 with twins, augmentation, a prolonged third stage, and a boggy fundus with tachycardia.
At 20 minutes old a newborn was alert and rooting. Now at 90 minutes she is in a deep sleep and hard to rouse, and her parents are worried. Which behavioral period is she in, and when will she wake?
The period of decreased responsiveness (30–120 min). She should wake for the second period of reactivity at about 2–8 hours.
A 39-week newborn weighs 4,300 g (LGA). The mother has gestational diabetes treated with insulin. What is the nurse's priority assessment, and why?
Blood glucose monitoring in the first hours after birth, because this LGA newborn is at risk for hypoglycemia.
A client at 35 weeks with preeclampsia develops new epigastric pain. Why should the nurse report this immediately?
It signals liver involvement, a severe feature that may mean HELLP syndrome and can come before a seizure.
A breastfeeding client is on postpartum day 4. Which of these findings are expected, and which need follow-up?
Expected: fundus 4 cm below, serosa, bilateral engorgement, pulse 64.
Needs follow-up: foul-smelling lochia and the left calf findings.
A partner calls about a client who is 2 weeks postpartum. She hasn't slept in 3 days, says the baby "isn't really ours," and hears a voice telling her to protect the world from him. What is the nurse's first instruction?
Don't leave her alone with the baby, and get her an emergency evaluation now. This is postpartum psychosis.
A 3-hour-old term newborn has these findings. Which ones require intervention?
Flaring and grunting, RR 72 at rest, glucose 38, and central cyanosis.
A breastfeeding client on postpartum day 10 has a red, hot, wedge-shaped area on one breast, body aches, and a temp of 101.4°F (38.6°C). Antibiotics are prescribed. What is the condition, and what should the nurse teach about feeding?
Mastitis. Keep breastfeeding often, including on the affected side, and finish all the antibiotics.
Four antepartum clients are on the unit. Which one should the nurse see first, and what is the likely problem?
The 34-week PPROM client. Fever with fetal tachycardia points to chorioamnionitis (intra-amniotic infection).