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Postpartum Assessment BUBBLE-HE Case Study
You have received report on 4 postpartum mothers and their newborns. You are beginning your assessments on your clients. Here is report on your first client.
Ms. Myna Alton, G2 P1011, delivered her baby girl Nedra by cesarean section due to a breech presentation 7 hours ago. She had spinal anesthesia with fentanyl
for surgery, and IV oxytocin in the recovery room. Her EBL was 600 ml. She has IV access in her left forearm, no IV fluids infusing now. She has stood at the
bedside once since birth. She tolerates clear liquids orally without nausea until 1 hour ago, now feels nauseous. She is breastfeeding and has done 3 feedings
since giving birth. Support is provided by her husband and her mother, who are present. Labs are normal, Blood type O Rh positive, GBS negative.
Please review your findings on Ms. Alton below, and then complete the table with your hypotheses about what is going on (normal vs. abnormal and why), what
your actions should be, and teaching completed with the client.
Findings Your hypothesis Your actions Your teaching
Pain 6/10, throbbing headache Spinal headache Lay her flat, give pain
whenever sitting up/standing medication. Call the
for last hour, 1/10 dull anesthesiologist.
incisional pain in abdomen.
No meds given for pain.
Vital signs BP 110/70, P 110, R 12, T 99.2 P could be due to pain Watch the patient
oral, Pulse ox 99%
Heart & S1, S2, regular, no abn.
Lungs Sounds, Lungs – vesicular all
lobes, no adventitious
sounds.
B Sl. Enlarged, soft, non-tender,
Breasts nipples everted, intact, no
redness or soreness
U Firm, sl. Tender, right of Full bladder Get her to the bathroom or
Uterus midline, 3 cm above bed pan/Cath her if she can’t
umbilicus walk.
B Indwelling catheter removed
Bladder 3 hours ago, no voiding since,
no urge to void.
B Last BM yesterday, no
Spring 2022
Postpartum Assessment BUBBLE-HE Case Study
You have received report on 4 postpartum mothers and their newborns. You are beginning your assessments on your clients. Here is report on your first client.
Ms. Myna Alton, G2 P1011, delivered her baby girl Nedra by cesarean section due to a breech presentation 7 hours ago. She had spinal anesthesia with fentanyl
for surgery, and IV oxytocin in the recovery room. Her EBL was 600 ml. She has IV access in her left forearm, no IV fluids infusing now. She has stood at the
bedside once since birth. She tolerates clear liquids orally without nausea until 1 hour ago, now feels nauseous. She is breastfeeding and has done 3 feedings
since giving birth. Support is provided by her husband and her mother, who are present. Labs are normal, Blood type O Rh positive, GBS negative.
Please review your findings on Ms. Alton below, and then complete the table with your hypotheses about what is going on (normal vs. abnormal and why), what
your actions should be, and teaching completed with the client.
Findings Your hypothesis Your actions Your teaching
Pain 6/10, throbbing headache Spinal headache Lay her flat, give pain
whenever sitting up/standing medication. Call the
for last hour, 1/10 dull anesthesiologist.
incisional pain in abdomen.
No meds given for pain.
Vital signs BP 110/70, P 110, R 12, T 99.2 P could be due to pain Watch the patient
oral, Pulse ox 99%
Heart & S1, S2, regular, no abn.
Lungs Sounds, Lungs – vesicular all
lobes, no adventitious
sounds.
B Sl. Enlarged, soft, non-tender,
Breasts nipples everted, intact, no
redness or soreness
U Firm, sl. Tender, right of Full bladder Get her to the bathroom or
Uterus midline, 3 cm above bed pan/Cath her if she can’t
umbilicus walk.
B Indwelling catheter removed
Bladder 3 hours ago, no voiding since,
no urge to void.
B Last BM yesterday, no
Spring 2022
