NORMAL POSTPARTUM NURSING
CARE EXAM1
Physical Postpartum Assessment - CORRECT ANSWER-BUBBLE HE
Breasts, Uterine Fundus, Bowel, Bladder, Lochia, Episotomy, Homan's Sign, Emotional
status
Breast Assessment - CORRECT ANSWER-Day 1-2 soft
Day 2-3 filling
Day 3-5 full, soften with breast feeding skin intact no soreness
Uterine Fundus Assessment - CORRECT ANSWER-1st 24 hours
Firm midline at level of umbilicus, involutes 1 cm a day
Bowel Assessment - CORRECT ANSWER-Active bowel sounds in all 4 quadrants,
bowel movement
Bladder Assessment - CORRECT ANSWER-No distention, able to void
Lochia Assessment - CORRECT ANSWER-Day 1 -3 Dark Rubra, dark red
Day 4-10 Serosa, brownish red or pink
Day 10 Alba, white
Episiotomy Assessment - CORRECT ANSWER-Assess for pain, redness, warmth,
swelling, or discharge
look for approximated edges
Homan's Sign Assessment - CORRECT ANSWER-Check for pain in the calf with leg
extended and dorsiflexion of the foot
Emotional Status Assessment - CORRECT ANSWER-Assess the patient to see if she
is able to care for herself and infant, able to sleep, assess mood, interest and
involvement with baby
Why should Nurse ask Patient to empty bladder before you assess the Fundus -
CORRECT ANSWER-Full bladder will displace the Uterus and raise the height of the
Fundus
Explain the Significance of a Boggy soft Uterus - CORRECT ANSWER-Boggy uterus
which is a inadequately contracted uterus causing softness rather than firm may
indicate Uterine Atony or retained Placental fragments
, Explain the standardized method for estimating Lochia after delivery - CORRECT
ANSWER-Blood loss is assessed after birth by the extent of a perineal pad saturation
Scant less than 2.5 cm
Light less than 10 cm
Moderate greater than 10cm
Heavy- one pad saturated within 2 hours
What position should the patient assume for Perineal Assessment - CORRECT
ANSWER-Lithotomy position
List and Explain the significance of the Components of the REEDA SCALE - CORRECT
ANSWER-Assessing Episiotomy
R= Redness
E= Edema
E= Ecchymosis
D= Discharge
A= Approximation
Medications used for Postpartum bleeding - CORRECT ANSWER-Dose/Route
Oxytocin 125-200 milliunits/minute IV
Oxytocin 10-20 units IM
Methylergonovine 0.2mg IM every 2-4 hrs up to 5 doses
Misoprostol 800-1000 mcg rectally one time
Postpartum hemorrhage saturation indications - CORRECT ANSWER-A perineal pad
saturated in 15 minutes or less and pooling of blood under the buttocks- excessive
blood loss
Identify comfort measures and rationales for discomfort of Hemorrhoids and Afterpains -
CORRECT ANSWER-Hemorrhoids=
Ice packs- reduce swelling
Sitz baths- promote circulation
Topical applications - hazel pads to reduce edema
After Pains=
Analgesics both non narcotic or narcotic
Mother and Newborn relationship assessment - CORRECT ANSWER-Love and
acceptance of one another by way of:
Sensual responses or interactions
Assessment:
Calling infant by name
Speaking about the infant (resemblance)
Contact while holding
CARE EXAM1
Physical Postpartum Assessment - CORRECT ANSWER-BUBBLE HE
Breasts, Uterine Fundus, Bowel, Bladder, Lochia, Episotomy, Homan's Sign, Emotional
status
Breast Assessment - CORRECT ANSWER-Day 1-2 soft
Day 2-3 filling
Day 3-5 full, soften with breast feeding skin intact no soreness
Uterine Fundus Assessment - CORRECT ANSWER-1st 24 hours
Firm midline at level of umbilicus, involutes 1 cm a day
Bowel Assessment - CORRECT ANSWER-Active bowel sounds in all 4 quadrants,
bowel movement
Bladder Assessment - CORRECT ANSWER-No distention, able to void
Lochia Assessment - CORRECT ANSWER-Day 1 -3 Dark Rubra, dark red
Day 4-10 Serosa, brownish red or pink
Day 10 Alba, white
Episiotomy Assessment - CORRECT ANSWER-Assess for pain, redness, warmth,
swelling, or discharge
look for approximated edges
Homan's Sign Assessment - CORRECT ANSWER-Check for pain in the calf with leg
extended and dorsiflexion of the foot
Emotional Status Assessment - CORRECT ANSWER-Assess the patient to see if she
is able to care for herself and infant, able to sleep, assess mood, interest and
involvement with baby
Why should Nurse ask Patient to empty bladder before you assess the Fundus -
CORRECT ANSWER-Full bladder will displace the Uterus and raise the height of the
Fundus
Explain the Significance of a Boggy soft Uterus - CORRECT ANSWER-Boggy uterus
which is a inadequately contracted uterus causing softness rather than firm may
indicate Uterine Atony or retained Placental fragments
, Explain the standardized method for estimating Lochia after delivery - CORRECT
ANSWER-Blood loss is assessed after birth by the extent of a perineal pad saturation
Scant less than 2.5 cm
Light less than 10 cm
Moderate greater than 10cm
Heavy- one pad saturated within 2 hours
What position should the patient assume for Perineal Assessment - CORRECT
ANSWER-Lithotomy position
List and Explain the significance of the Components of the REEDA SCALE - CORRECT
ANSWER-Assessing Episiotomy
R= Redness
E= Edema
E= Ecchymosis
D= Discharge
A= Approximation
Medications used for Postpartum bleeding - CORRECT ANSWER-Dose/Route
Oxytocin 125-200 milliunits/minute IV
Oxytocin 10-20 units IM
Methylergonovine 0.2mg IM every 2-4 hrs up to 5 doses
Misoprostol 800-1000 mcg rectally one time
Postpartum hemorrhage saturation indications - CORRECT ANSWER-A perineal pad
saturated in 15 minutes or less and pooling of blood under the buttocks- excessive
blood loss
Identify comfort measures and rationales for discomfort of Hemorrhoids and Afterpains -
CORRECT ANSWER-Hemorrhoids=
Ice packs- reduce swelling
Sitz baths- promote circulation
Topical applications - hazel pads to reduce edema
After Pains=
Analgesics both non narcotic or narcotic
Mother and Newborn relationship assessment - CORRECT ANSWER-Love and
acceptance of one another by way of:
Sensual responses or interactions
Assessment:
Calling infant by name
Speaking about the infant (resemblance)
Contact while holding
