NUR 230 Maternity Assessment 2
Questions and Answers
Changes in Reproductive system: Uterus - ANSWER-Involution - return of uterus to
prepregnant state
Uterus may rise above the umbilicus by 1cm within the first 12 hours
Within 24 hours should be at umbilicus (the level of a 20 week gestation)
Uterine involution should occur at a rate of 1-2 cm per day and at 2 weeks postpartum
should not be felt externally
BUBBLEEE Assessment - ANSWER-Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Epidural Site
Emotional Status
PROMOTING RECOVERY AND SELF-CARE (Activity and Rest) - ANSWER-
•Encourage early and frequent ambulation
•Rest as much as possible, sleep when infant sleeps
PROMOTING RECOVERY AND SELF-CARE (Nourishment) - ANSWER-•Formula
Feeding Mom
•Breastfeeding Mom
PROMOTING RECOVERY AND SELF-CARE (Elimination) - ANSWER-•Voiding
Patterns
•Bowel Patterns
PROMOTING RECOVERY AND SELF-CARE (Perineal Care) - ANSWER-•Perineal
Hygiene
•Topical Medications
•Ice Packs
•Sitz Baths
Bladder and Bowel - ANSWER-•COCA- Color, odor, consistency, amount; Time of last
void/BM
•Distended bladder
•Flatus
•Auscultate bowel sounds
Lochia - ANSWER-•Rubra- 1-4 days, bright red
, •Serosa- 4-10 days, pink to brown
•Alba- 10 days to 6 weeks, white to yellowish
•Odor similar to menstrual flow, foul odor indicates infection
•Presence of clots
Early postpartum hemorrhage - ANSWER-•Within first 24 hours
•Most common cause is uterine atony
Early Postpartum Hemorrhage Risk Factors - ANSWER--macrosomia
-multiple gestation
-polyhydramnios
-chorioamnionitis
-prolonged labor
-use of Magnesium sulfate
-use of oxytocin (Pitocin)
Early postpartum hemorrhage observation - ANSWER-•Unrepaired lacerations of
perineum or vaginal canal
•Monitor for continuous trickle of bright red blood
•Hematoma's of perineal area or vaginal
-patient complains of unrelieved pain or pressure
-may or may not be able to see
-can be caused by forceps or vacuum delivery
Postpartum Medications - ANSWER-•oxytocin (Pitocin) 20 U in 1000ml of LR or NS
•methylergonovine maleate (Methergine)
dose: 0.2mg/ q4/ x6 IM
PO 0.2 mg q 4
Check Blood Pressure: DO NOT give if hypertensive
Postpartum medications (prostaglandins) - ANSWER-Prostaglandins:
•Misoprostol (Cytotec)- rectally, sublingual, buccal, or PO x1
•Carboprost Tromethamine (Hemabate)- IM or intrauterine q15-90 minutes up to 8
doses
•Dinoprostone (Prostin E2)-rectally (contraindicated for hypotension)
•
•Side effects: nausea, vomiting and diarrhea
Late Postpartum Hemorrhage - ANSWER-•More than 24 hrs but less than a week after
birth
•Common cause- retained placenta
After the first postpartum day the most common
cause of uterine atony is retained placental
fragments. The nurse must check for the
Questions and Answers
Changes in Reproductive system: Uterus - ANSWER-Involution - return of uterus to
prepregnant state
Uterus may rise above the umbilicus by 1cm within the first 12 hours
Within 24 hours should be at umbilicus (the level of a 20 week gestation)
Uterine involution should occur at a rate of 1-2 cm per day and at 2 weeks postpartum
should not be felt externally
BUBBLEEE Assessment - ANSWER-Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Epidural Site
Emotional Status
PROMOTING RECOVERY AND SELF-CARE (Activity and Rest) - ANSWER-
•Encourage early and frequent ambulation
•Rest as much as possible, sleep when infant sleeps
PROMOTING RECOVERY AND SELF-CARE (Nourishment) - ANSWER-•Formula
Feeding Mom
•Breastfeeding Mom
PROMOTING RECOVERY AND SELF-CARE (Elimination) - ANSWER-•Voiding
Patterns
•Bowel Patterns
PROMOTING RECOVERY AND SELF-CARE (Perineal Care) - ANSWER-•Perineal
Hygiene
•Topical Medications
•Ice Packs
•Sitz Baths
Bladder and Bowel - ANSWER-•COCA- Color, odor, consistency, amount; Time of last
void/BM
•Distended bladder
•Flatus
•Auscultate bowel sounds
Lochia - ANSWER-•Rubra- 1-4 days, bright red
, •Serosa- 4-10 days, pink to brown
•Alba- 10 days to 6 weeks, white to yellowish
•Odor similar to menstrual flow, foul odor indicates infection
•Presence of clots
Early postpartum hemorrhage - ANSWER-•Within first 24 hours
•Most common cause is uterine atony
Early Postpartum Hemorrhage Risk Factors - ANSWER--macrosomia
-multiple gestation
-polyhydramnios
-chorioamnionitis
-prolonged labor
-use of Magnesium sulfate
-use of oxytocin (Pitocin)
Early postpartum hemorrhage observation - ANSWER-•Unrepaired lacerations of
perineum or vaginal canal
•Monitor for continuous trickle of bright red blood
•Hematoma's of perineal area or vaginal
-patient complains of unrelieved pain or pressure
-may or may not be able to see
-can be caused by forceps or vacuum delivery
Postpartum Medications - ANSWER-•oxytocin (Pitocin) 20 U in 1000ml of LR or NS
•methylergonovine maleate (Methergine)
dose: 0.2mg/ q4/ x6 IM
PO 0.2 mg q 4
Check Blood Pressure: DO NOT give if hypertensive
Postpartum medications (prostaglandins) - ANSWER-Prostaglandins:
•Misoprostol (Cytotec)- rectally, sublingual, buccal, or PO x1
•Carboprost Tromethamine (Hemabate)- IM or intrauterine q15-90 minutes up to 8
doses
•Dinoprostone (Prostin E2)-rectally (contraindicated for hypotension)
•
•Side effects: nausea, vomiting and diarrhea
Late Postpartum Hemorrhage - ANSWER-•More than 24 hrs but less than a week after
birth
•Common cause- retained placenta
After the first postpartum day the most common
cause of uterine atony is retained placental
fragments. The nurse must check for the
