Postpartum Assessment

Question 1

What does BUBBLETEA stand for?

Answer 1

B → Breast Assessment
U → Uterus Assessment
B → Bladder Assessment
B → Bowel Function Assessment
L → Lochia (PP Vaginal discharge)
E → Episiotomy
T → Thromboembolism Check
E & A → Emotional Adaptation

Question 2

List 3 expected findings on postpartum breast assessment

Answer 2

1) Breasts should be soft & nontender
2) Mature milk typically produced by 3-5 days; prior is colostrum
3) Intact skin on nipples; nipples everted; absence of lumps or swelling

Question 3

List 3 potential problems seen on postpartum breast assessment

Answer 3

1) Cracked nipples
2) Inverted nipples
3) Engorgement

Question 4

How can cracked nipples occur & what should we do to help resolve this?

Answer 4

Caused by → improper latch
→ requires assessment
→ check latch
→ apply topical cream

Question 5

What are inverted nipples & how can they cause problem postpartum?

Answer 5

Nipples retract into skin
→ very hard for infants to latch
→ may require a nipple shield

Question 6

What is engorgement of breasts & how can we identify it in postpartum mothers?

Answer 6

Red, swollen, warm, very painful
→ palpation will reveal tenderness
→ address with comfort measures

Question 7

What is the purpose of postpartum uterus assessment?

Answer 7

Uterus MUST contract to stop PP bleeding

Question 8

Explain how a fundal check is performed

Answer 8

One hand supports symphysis pubis, the other palpates the fundus

Question 9

What should the fundus feel like the day of delivery?

Answer 9

Firm melon
→ at the level of the umbilicus (firm fundus helps control bleeding)

Question 10

Explain uterine involution Hint: 2

Answer 10

1) Uterus shrinks ~ 1 cm (or fingerbreadth) per day
2) By day 10, it should not be palpable

Question 11

What would a PP mother be at risk for if her fundus is not shrinking at a finger per day?

Answer 11

Subinvolution → risk for hemorrhage

Question 12

Abnormal uterine finding:

Boggy uterus Hint: 3

Answer 12

1) Soft, non-contracted uterus
2) Risk of bleeding → can cause hemorrhage
3) Massage the fundus → if ineffective, give uterotonics

Question 13

List 5 reasons it is important to perform a bladder assessment on PP mother

Answer 13

1) Post-delivery, the bladder can lose tone
2) Full bladder can displace uterus (upward & right), making it boggy
3) Full bladder increases hemorrhage risk
4) Increased diuresis
5) Increased risk of UTI → get the foley out ASAP

Question 14

List 3 nursing interventions when performing a bladder assessment

Answer 14

1) Ask mom when she last voided
2) Encourgae her to empty her bladder
3) If all else is ineffective → perform straight cath

Question 15

List 3 ways to help PP mother empty her bladder

Answer 15

1) Turn running water on
2) Pour warm water on perineum
3) Encourage her to lean forward to help void

Question 16

List 3 reasons PP moms are at risk for urinary retention

Answer 16

1) Bladder tone is decreased
2) Periurethral trauma (tearing downward)
3) Pitocin can cause urinary retention

Question 17

Bowel Function Assessment:

After birth there may be increase ____ & decreased ____

Answer 17

Increased appetite
Decreased peristalsis → due to elevated progesterone

Question 18

Bowel Function Assessment:

List 4 postpartum risks

Answer 18

1) Risk of constipation & hemorrhoids
2) Fear of pain (perineal stitches) can contribute to constipation
3) Prenatal vitamins, iron, & opioids can constipate the bowel
4) C-section → surgery & anesthesia slows down bowel function

Question 19

True or False:

It is uncommon for mother to have absent bowel sounds after surgery (i.e. C-section) & Anesthesia

Answer 19

FALSE → it is NOT uncommon b/c surgery & anesthesia can slow down peristalsis

Question 20

Bowel Function Assessment:

List 4 management options to promote BM

Answer 20

1) Fluids
2) Ambulation
3) Fiber intake
4) Stool softeners & laxatives as prescribed

Question 21

List the 3 phases of PP Lochia & what it looks like

Answer 21

1) Rubra → bright red d/c in first 1-2 days
2) Serosa → pink/ brownish d/c (similar to period end)
3) Alba → white or creamy d/c at the end

Question 22

List the 4 amount classifications of Lochia (PP vaginal d/c)

Answer 22

1) Scant → only when wiping or < 1 in stain
2) Small → < 4 in stain
3) Moderate → < 6 in stain
4) Heavy → saturated pad within 1 hr

Question 23

When should we be concerned about Lochia?

Answer 23

1) Soaking pad < 1 hr = alert
2) Soaking pad in 15 min or passing egg-sized clot = likely hemorrhage

Question 24

List 5 interventions for assessing abnormal Lochia in PP mother

Answer 24

1) Reassess fundus for firmness & location
2) Ensure bladder is empty
3) Consider uterine atony (loss of tone)
4) If uterus is firm but bleeding continues → suspect cervical tear / unrepaired laceration
5) Notify provider & anticipate orders

Question 25

What does the mnemonic REEDA stand for when assessing episiotomy?

Answer 25

R → redness E → edema E → ecchymosis D → drainage A → approximation **same mnemonic used for C-section incision**

Question 26

List 2 actions taken by the nurse if episiotomy looks abnormal

Answer 26

1) Document concerning signs 2) Report to provider if needed

Question 27

Why are PP mothers at risk for DVT?

Answer 27

Pregnancy is a hypercoagulable state

Question 28

List 5 signs of DVT in PP mother

Answer 28

1) Calf pain (esp. unilateral) 2) Pain 3) Swelling 4) Redness 5) Palpable cord-like knot

Question 29

Which PP DVT assessment is outdated & no longer used?

Answer 29

Homan's sign

Question 30

List 3 actions taken if signs of DVT present in PP mother

Answer 30

1) Notify provider 2) Anticipate orders → doppler study, possible blood work (D-dimer) 3) Bedrest

Question 31

Why should we avoid ambulation if suspected DVT?

Answer 31

To prevent PE

Question 32

Emotional adaptation: List 4 important things to educate about becoming a mother

Answer 32

1) Process of developing a new identity as a mother can take 3-10 mos 2) Common to feel inadequate at first 3) Teach parent teaching skills 4) Encourage mom to find support → existing support; online/ community resources

Question 33

Emotional adaptation: How long does the restorative period take to resolve?

Answer 33

4-6 weeks

Question 34

List 4 things to note/ look for regarding bonding & mood in PP mothers

Answer 34

1) Signs of bonding → holding; eye contact 2) Screen for PP depression 3) Sx may not show in hospital 4) If PMAD present during pregnancy it can worsen PP

Question 35

What is the estimated blood loss for a vaginal delivery?

Answer 35

200-500 mL

Question 36

What is the estimated blood loss for a C-section?

Answer 36

500-1000 mL

Question 37

How long after delivery does cardiac output stay elevated for?

Answer 37

24-48 hrs

Question 38

How frequent should VS be checked after delivery?

Answer 38

Every 15 mins for 1-2 hrs, then per protocol

Question 39

What should happen to VS after delivery (BP; HR; RR; & Temp)

Answer 39

BP → should return to baseline HR → Decreased due to fluid shift (50-70 bpm is common) RR → decreased Temp → Should remain below 100.3°F

Question 40

What are postpartum chills?

Answer 40

Common shaking after delivery due to fluid shift, normal but requires reassurance

Question 41

What is included in neurological PP assessment? **Hint: 4**

Answer 41

1) Epidural wears off → pt still a falls risk 2) Decreased motor ability & sensory perception 3) Test muscle strength before ambulation 4) Assess for H/A

Question 42

List 3 reasons it is important to assess for H/A in PP assessment

Answer 42

1) Fatigue; positioning during BF 2) Post-epidural spinal H/A 3) Postpartum preeclampsia

Question 43

How does a Post-epidural spinal H/A occur?

Answer 43

CSF may leak out causing a H/A; if mom lays down & is fine and then sits up and has excruciating pain

Question 44

What can be administered immediately after delivery to reduce risk of bleeding & help uterus contract?

Answer 44

Oxytocin (IM or IV)

Question 45

List 3 other ways to monitor for bleeding after delivery

Answer 45

1) Keeping bladder empty 2) Monitor CBC 3) Monitor fundal height & consistency

Question 46

What is usually indicated if Hgb is < 7 after delivery?

Answer 46

**Transfusion** → should also consider iron supplementation (PO or IV)

Question 47

List 3 teaching points for PP mother to prevent bleeding complications

Answer 47

1) Fundal massage 2) Progression of Lochia 3) Encourage voiding q2-3h