NUR 267 EXAM 2 STUDY GUIDE
WITH COMPLETE SOLUTION
What does B.U.B.B.L.E. stand for? -ANSWER Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy/Emotions
How to assess breasts postpartum:
(breastfeeding vs. nonbreastfeeding)-ANSWER Breastfeeding:
-Assess if soft/non-tender or firm and warm
-Check for nipple tears/excoriation
-Assess latch of infant
Nonbreastfeeding:
-Assess for engorgement
What education can you provide regarding breasts postpartum?-ANSWER
Breastfeeding:
-Wear supportive bra
-Use breast pump
,-Warm compress/massage
before feeding
-Ice after feeding
-Promote different holding styles for feeding
-Ensure baby feeds frequently and well to empty each breast
NonBreastfeeding:
-Wear supportive bra
-Apply ice
-Avoid stimulating
Cold cabbage leaves in bra comfort to sensitivity
Chief goals for assessing postpartum uterus: - ANSWER -Infection prevention
Excessive bleeding prevention
Bladder distension prevention
How is uterine tone maintained post-labor? - ANSWER Fundal massage
How often to assess postpartum uterus? - ANSWER -q15 minutes (1st hour)
-q30 minutes (2nd hour
-q4h (first 24 hours)
-Assess every shift after 24hrs
What do you do if you find a boggy uterus? - ANSWER Perform fundal
massage until firm, recheck in 10-15mins. If it has not firmed up, notify
,provider
What is given for boggy uterus? - ANSWER Pitocin (Oxytocin)
What is the function of oxytocin (Pitocin)? - ANSWER Hormone that causes
uterine contraction
What naturally releases oxytocin (Pitocin)? - ANSWER Posterior pituitary
What is the #1 cause of postpartum hemorrhage? - ANSWER Boggy uterus
If the uterus is not midline upon assessment, what do we try and do first?
-ANSWER Have patient try and use the bathroom
How to assess the bladder postpartum + nursing actions: -ANSWER -Last
time of void
-Warm water to help aid in starting urine stream
-May need bladder scan, straight cath, or foley
, How many hours post birth should the patient have urinated and how much?
-ANWER 2-4 hours post birth, voiding at least 300mL
How to assess the bowels post birth + nursing interventions: -ANWER
-Assess for time of last BM
-Fluids + mobilization
-Stool softener
Patient teaching related to bowel elimination pattern postpartum: -ANWER
-May not have a BM for several days
-Hemorrhoids, episiotomy, or c-section can make having a BM more difficult
How to assess lochia postpartum:
**REMEMBER A.C.C.O!!!! - ANSWER Amount
Clots
Color
Odor
WITH COMPLETE SOLUTION
What does B.U.B.B.L.E. stand for? -ANSWER Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy/Emotions
How to assess breasts postpartum:
(breastfeeding vs. nonbreastfeeding)-ANSWER Breastfeeding:
-Assess if soft/non-tender or firm and warm
-Check for nipple tears/excoriation
-Assess latch of infant
Nonbreastfeeding:
-Assess for engorgement
What education can you provide regarding breasts postpartum?-ANSWER
Breastfeeding:
-Wear supportive bra
-Use breast pump
,-Warm compress/massage
before feeding
-Ice after feeding
-Promote different holding styles for feeding
-Ensure baby feeds frequently and well to empty each breast
NonBreastfeeding:
-Wear supportive bra
-Apply ice
-Avoid stimulating
Cold cabbage leaves in bra comfort to sensitivity
Chief goals for assessing postpartum uterus: - ANSWER -Infection prevention
Excessive bleeding prevention
Bladder distension prevention
How is uterine tone maintained post-labor? - ANSWER Fundal massage
How often to assess postpartum uterus? - ANSWER -q15 minutes (1st hour)
-q30 minutes (2nd hour
-q4h (first 24 hours)
-Assess every shift after 24hrs
What do you do if you find a boggy uterus? - ANSWER Perform fundal
massage until firm, recheck in 10-15mins. If it has not firmed up, notify
,provider
What is given for boggy uterus? - ANSWER Pitocin (Oxytocin)
What is the function of oxytocin (Pitocin)? - ANSWER Hormone that causes
uterine contraction
What naturally releases oxytocin (Pitocin)? - ANSWER Posterior pituitary
What is the #1 cause of postpartum hemorrhage? - ANSWER Boggy uterus
If the uterus is not midline upon assessment, what do we try and do first?
-ANSWER Have patient try and use the bathroom
How to assess the bladder postpartum + nursing actions: -ANSWER -Last
time of void
-Warm water to help aid in starting urine stream
-May need bladder scan, straight cath, or foley
, How many hours post birth should the patient have urinated and how much?
-ANWER 2-4 hours post birth, voiding at least 300mL
How to assess the bowels post birth + nursing interventions: -ANWER
-Assess for time of last BM
-Fluids + mobilization
-Stool softener
Patient teaching related to bowel elimination pattern postpartum: -ANWER
-May not have a BM for several days
-Hemorrhoids, episiotomy, or c-section can make having a BM more difficult
How to assess lochia postpartum:
**REMEMBER A.C.C.O!!!! - ANSWER Amount
Clots
Color
Odor
