Anne Nielsen
NURS 53 – Maternal & Newborn Care
Case Study #1 – Postpartum
Patient Data:
The patient experienced a normal and healthy pregnancy, though her labor
was prolonged with ruptured membranes for 28 hours. She received an
epidural block for pain relief and internal monitors were utilized. Ultimately,
she had a spontaneous vaginal delivery with an estimated blood loss (EBL) of
400 ml. Four hours after delivery, the patient voided 650 cc at 3 hours
postpartum. The fundus is firm and tender, located 1 fingerbreadth above
the umbilicus. The current peri pad has been in place for 1 hour and is
saturated with heavy rubra lochia. The MD has ordered 20 units to 1L of
lactated ringers to run at 250 cc/hour for the heavy lochia. Vital signs
indicate a temperature of 38.2°C (100.7°F), pulse rate of 104, respiratory
rate of 20, blood pressure of 110/70, and oxygen saturation of 100%. She is
on a regular diet, and the baby is rooming-in. While she is enthusiastic about
having the baby rooming in, she expresses feeling very tired and hopes to
rest. The patient's breasts are soft, and both nipples are erect and intact.
Due to fatigue, I assisted with breastfeeding positioning. The patient reports
experiencing cramping, intensified to about 5 out of 10 during breastfeeding,
and expresses a desire to rest. She mentions feeling nauseated and
expresses concern about her well-being.
Analyze:
Normal Findings:
Both her O2 saturation and respiratory rate are within normal limits. Normal
respiratory rates typically indicate that a person's breathing is within a
healthy range and that their respiratory system is functioning properly. The
normal respiratory rate for adults at rest is usually between 12 to 20 breaths
per minute. Higher respiratory rates may indicate conditions such as anxiety,
fever, or respiratory distress, while lower rates may indicate sedation or
certain medical conditions affecting breathing (Ricci, 2021). Normal oxygen
saturation levels indicate that the blood is carrying enough oxygen to the
body's tissues and organs. Oxygen saturation (SpO2) is typically measured
as a percentage and represents the percentage of oxygenated hemoglobin in
the blood (Ricci, 2021). In healthy individuals, normal oxygen saturation
levels typically range between 95% and 100%. Her blood pressure of 110/70
is also within normal limits, a normal blood pressure reading indicates that
This study source was downloaded by 100000899527527 from CourseHero.com on 07-05-2025 14:28:01 GMT -05:00
https://www.coursehero.com/file/233772638/Postpartum-Case-Studydocx/
, the pressure of blood against the walls of the arteries is within a healthy
range.
Abnormal Findings:
Both her pulse rate and temperature are abnormal, both being elevated. The
patient’s pulse rate of 104 suggests potential causes such as anxiety,
infection, significant blood loss, or hemorrhage in the patient (Ricci, 2021).
The patient’s temperature of 38.2 C (100.7 F) may indicate a possible
infection, which directly correlates with the elevated heart rate. The other
abnormal findings would be the location of her fundus and the lochia
saturation of her peri pad. According to Ricci, “during the first 12 hours
postpartum, the fundus of the uterus is located at the level of the umbilicus.
Over the first few days after birth, the uterus typically descends from the
level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day” (Ricci,
2021). The assessment reveals her fundus to be 1 fingerbreadth above the
umbilicus, possibly indicating displacement due to a distended bladder,
increasing the risk for hemorrhage (Ricci, 2021). The moderate amount of
dark red lochia drainage on the peri pad also may indicate the uterus is not
properly contracting adequately to control bleeding (Ricci, 2021).
Missing Information:
There is quite a bit of missing information in this scenario such as her age,
the gestational age of the baby at the time of delivery, her past obstetric
history, her blood type, and lab information. A woman's obstetric history
provides valuable information about her previous pregnancies, deliveries,
and any complications she may have experienced. This information helps
healthcare providers assess the woman's risk factors for potential
complications in the current postpartum period. An obstetric history serves
as a valuable tool for individualized care planning, risk assessment, and
management in the postpartum period, promoting the well-being of both the
mother and baby. A woman’s age is also vital information as it provides us
with possible individual risks and needs during postpartum as we will
typically see complications with very young patients or older patients, all this
information should be found within the patient’s chart in EPIC, assuming they
have received prenatal care. It is crucial to know the mother’s blood type not
only for possible infusions in a postpartum hemorrhage situation but also to
know the mother’s Rh factor. This information should also be in the chart, if
not obtained labs should be drawn immediately. Lab values, specifically for
hematocrit and hemoglobin should also be available and if not, drawn
immediately. Hematocrit and hemoglobin levels are monitored to assess for
signs of anemia resulting from blood loss (Ricci, 2021).
Nursing Diagnosis:
This study source was downloaded by 100000899527527 from CourseHero.com on 07-05-2025 14:28:01 GMT -05:00
https://www.coursehero.com/file/233772638/Postpartum-Case-Studydocx/
NURS 53 – Maternal & Newborn Care
Case Study #1 – Postpartum
Patient Data:
The patient experienced a normal and healthy pregnancy, though her labor
was prolonged with ruptured membranes for 28 hours. She received an
epidural block for pain relief and internal monitors were utilized. Ultimately,
she had a spontaneous vaginal delivery with an estimated blood loss (EBL) of
400 ml. Four hours after delivery, the patient voided 650 cc at 3 hours
postpartum. The fundus is firm and tender, located 1 fingerbreadth above
the umbilicus. The current peri pad has been in place for 1 hour and is
saturated with heavy rubra lochia. The MD has ordered 20 units to 1L of
lactated ringers to run at 250 cc/hour for the heavy lochia. Vital signs
indicate a temperature of 38.2°C (100.7°F), pulse rate of 104, respiratory
rate of 20, blood pressure of 110/70, and oxygen saturation of 100%. She is
on a regular diet, and the baby is rooming-in. While she is enthusiastic about
having the baby rooming in, she expresses feeling very tired and hopes to
rest. The patient's breasts are soft, and both nipples are erect and intact.
Due to fatigue, I assisted with breastfeeding positioning. The patient reports
experiencing cramping, intensified to about 5 out of 10 during breastfeeding,
and expresses a desire to rest. She mentions feeling nauseated and
expresses concern about her well-being.
Analyze:
Normal Findings:
Both her O2 saturation and respiratory rate are within normal limits. Normal
respiratory rates typically indicate that a person's breathing is within a
healthy range and that their respiratory system is functioning properly. The
normal respiratory rate for adults at rest is usually between 12 to 20 breaths
per minute. Higher respiratory rates may indicate conditions such as anxiety,
fever, or respiratory distress, while lower rates may indicate sedation or
certain medical conditions affecting breathing (Ricci, 2021). Normal oxygen
saturation levels indicate that the blood is carrying enough oxygen to the
body's tissues and organs. Oxygen saturation (SpO2) is typically measured
as a percentage and represents the percentage of oxygenated hemoglobin in
the blood (Ricci, 2021). In healthy individuals, normal oxygen saturation
levels typically range between 95% and 100%. Her blood pressure of 110/70
is also within normal limits, a normal blood pressure reading indicates that
This study source was downloaded by 100000899527527 from CourseHero.com on 07-05-2025 14:28:01 GMT -05:00
https://www.coursehero.com/file/233772638/Postpartum-Case-Studydocx/
, the pressure of blood against the walls of the arteries is within a healthy
range.
Abnormal Findings:
Both her pulse rate and temperature are abnormal, both being elevated. The
patient’s pulse rate of 104 suggests potential causes such as anxiety,
infection, significant blood loss, or hemorrhage in the patient (Ricci, 2021).
The patient’s temperature of 38.2 C (100.7 F) may indicate a possible
infection, which directly correlates with the elevated heart rate. The other
abnormal findings would be the location of her fundus and the lochia
saturation of her peri pad. According to Ricci, “during the first 12 hours
postpartum, the fundus of the uterus is located at the level of the umbilicus.
Over the first few days after birth, the uterus typically descends from the
level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day” (Ricci,
2021). The assessment reveals her fundus to be 1 fingerbreadth above the
umbilicus, possibly indicating displacement due to a distended bladder,
increasing the risk for hemorrhage (Ricci, 2021). The moderate amount of
dark red lochia drainage on the peri pad also may indicate the uterus is not
properly contracting adequately to control bleeding (Ricci, 2021).
Missing Information:
There is quite a bit of missing information in this scenario such as her age,
the gestational age of the baby at the time of delivery, her past obstetric
history, her blood type, and lab information. A woman's obstetric history
provides valuable information about her previous pregnancies, deliveries,
and any complications she may have experienced. This information helps
healthcare providers assess the woman's risk factors for potential
complications in the current postpartum period. An obstetric history serves
as a valuable tool for individualized care planning, risk assessment, and
management in the postpartum period, promoting the well-being of both the
mother and baby. A woman’s age is also vital information as it provides us
with possible individual risks and needs during postpartum as we will
typically see complications with very young patients or older patients, all this
information should be found within the patient’s chart in EPIC, assuming they
have received prenatal care. It is crucial to know the mother’s blood type not
only for possible infusions in a postpartum hemorrhage situation but also to
know the mother’s Rh factor. This information should also be in the chart, if
not obtained labs should be drawn immediately. Lab values, specifically for
hematocrit and hemoglobin should also be available and if not, drawn
immediately. Hematocrit and hemoglobin levels are monitored to assess for
signs of anemia resulting from blood loss (Ricci, 2021).
Nursing Diagnosis:
This study source was downloaded by 100000899527527 from CourseHero.com on 07-05-2025 14:28:01 GMT -05:00
https://www.coursehero.com/file/233772638/Postpartum-Case-Studydocx/
