NURS 420 Exam 3 Study Guide Part 2 Ch. 16

Nursing Assessment in the Postpartum Period

Typically includes vital signs, pain level, epidural site inspection for infection, and a systematic head-to-toe review of body systems.

The acronym BUBBLE-EE—breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status—can be used as a guide for this head-to-toe review. While assessing the patient and their family during the postpartum period, be alert for danger signs

BUBBLE Acronym

•B = Breasts — firmness, engorgement, nipple integrity, lactation

•U = Uterus — fundal height, position (midline?), firmness (firm vs. boggy)

•B = Bladder — distension, voiding, output

•B = Bowel — bowel sounds, BM, flatus, appetite

•L = Lochia — type, color, amount, odor, clots

•E = Episiotomy/Perineum — REEDA assessment, hematoma

•Some facilities add: E = Emotional/Extremities — mood, bonding, leg assessment for DVT

What is the frequency of VS and BUBBLE assessments during the first hour postpartum?

Every 15 minutes

What is the frequency of VS and BUBBLE assessments during the second hour postpartum?

Every 30 minutes

What is the frequency of VS and BUBBLE assessments during the first 24 hours postpartum?

Every 4 hours

What is the frequency of VS and BUBBLE assessments after 24 hours postpartum?

Every shift (remember to always follow institutional protocol).

Vital Signs Assessment: Temperature

Normal Range: 36.2-38°C (97.2-100.4°F)

Slight elevation during first 24 hours; normal afterward.

This elevation may be the result of dehydration, sweating, or diaphoresis. The rise in temperature can also be attributed to the systemic absorption of metabolites accumulated due to muscle contractions.

Should be normal after 24 hours with the replacement of fluids lost during labor and birth.

A temperature above 99°F (37.2°C) at any time, or an abnormal temperature after the first 24 hours may indicate infection and must be reported.

Use a consistent measurement technique (oral, axillary, or tympanic) to get the most accurate readings.

Vital Signs Assessment: Pulse

Normal Range: 50–90 bpm

In the first few days the pulse may be as low as 40 to 80 bpm; puerperal bradycardia is common and NORMAL

Tachycardia in the postpartum patient can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Any pulse rate higher than 100 bpm warrants further investigation to rule out complications

[NCLEX PEARL] Postpartum bradycardia (50–70 bpm) is a normal finding due to increased stroke volume. Tachycardia should raise concern for hemorrhage, infection, or pain.

Vital Signs Assessment: Respirations

Normal Range: 16 to 20 breaths per minute (Text: 12-20)

Any change in respiratory rate out of the normal range might indicate pulmonary edema, atelectasis (a side effect of epidural anesthesia), or pulmonary embolism (PE) and must be reported.

Lungs should be clear on auscultation.

Vital Signs Assessment: Blood pressure

Within usual range of patient.

An increase in BP could indicate gestational hypertension, while a decrease could indicate dehydration, shock, orthostatic hypotension, or a side effect of epidural anesthesia.

Postpartum onset of preeclampsia may occur from 2 days to 6 weeks following birth, and investigation is necessary if the BP is higher than 140/90 mm Hg.

Vital Signs Assessment: Pain

Goal between 0 and 2 on pain scale.

Many postpartum orders will have the nurse premedicate the patient routinely for afterbirth pains rather than waiting for the patient to experience them first.

If the patient has severe pain in the perineal region despite the use of physical comfort measures, check for a hematoma by inspecting and palpating the area. If one is found, notify the health care provider immediately.

Ensuring Safety During Ambulation

•First ambulation should be with nurse assistance. Elevate head of bed for a few minutes before ambulating. Have the patient sit on the edge of the bed (dangle) before standing.

•Orthostatic hypotension risk: Especially after epidural/spinal anesthesia, blood loss, or prolonged bed rest. Monitor for dizziness, lightheadedness, visual changes.

•Change positions slowly — sit → stand → walk. Help client stand up and stay with her

•Ensure call light is within reach and patient knows how to use it.

•Non-slip footwear required.

•Assess motor/sensory function before ambulation if regional anesthesia was used.

•Ensure IV/Foley/drains are secured and managed during ambulation. Ambulate alongside client and provide support if needed

Additional safeguards from the textbook: Check for low hemoglobin and hematocrit on lab work before ambulating the patient.

Sources of Postpartum Pain

•Uterine cramping / afterpains — especially multiparas and breastfeeding persons

•Perineal trauma — laceration, episiotomy repair

•Hemorrhoids — painful, swollen rectal veins

•Breast engorgement — bilateral breast fullness and tenderness

•Headache — especially post-dural puncture headache (PDPH) after spinal anesthesia

•Incision pain — C-section surgical site

•Nipple soreness — from breastfeeding, poor latch

•Infection

Postpartum Pain Management: Analgesia

1. Oral Analgesia: Acetaminophen, Ibuprofen, Oxycodone

2. IV, non-narcotic: Acetaminophen, ketoralac

3. NSAIDs (ibuprofen/ketorolac)-Inhibit prostaglandin-Decrease inflammatory responses-Effective in peripheral tissues

4. Epidural/Spinal: Duramorph

5. PCA: dilaudid, morphine

6. For moderate to severe pain, a narcotic analgesic such as codeine or oxycodone in conjunction with aspirin or acetaminophen may be prescribed. Instruct the patient about the adverse effects of any medication prescribed.

7. Also inform the patient that the drugs are secreted in breast milk. Nearly all medications that the patient takes are passed into their breast milk; however, mild analgesics (e.g., acetaminophen or ibuprofen) are considered relatively safe for breastfeeding people.

8. Administering a mild analgesic approximately an hour before breastfeeding will usually relieve afterpains and/or perineal discomfort.

What are common side effects of narcotics used for postpartum pain?

Pruritus, nausea and vomiting, urinary retention, respiratory depression, sedation, and decreased peristalsis

Pharmacologic Management

•NSAIDs (ibuprofen 600–800 mg): First-line for afterpains and perineal pain. Anti-inflammatory and analgesic. Also ketorolac (Toradol) for moderate-severe pain.

•Acetaminophen (Tylenol): Safe analgesic and antipyretic. Often alternated with NSAIDs.

•Opioids: Short-term use for severe pain (e.g., post-C-section). Monitor for sedation, respiratory depression, constipation, and neonatal effects if breastfeeding.

•Benzocaine spray/foam: Topical anesthetic for perineal pain.

•Dermoplast spray: Combination anesthetic + antiseptic spray for perineum.

•Stool softeners (docusate sodium/Colace): Prevent straining with BM; standard for all PP patients, especially after opioid use or perineal repair.

•Topical hydrocortisone: For hemorrhoid inflammation and itching.

Non-Pharmacologic Management

•Ice packs to perineum: During first 24 hours — reduces edema and provides analgesic effect.

•Sitz baths: After 24 hours — warm water promotes circulation, healing, and comfort.

•Positioning and pillow support (side-lying, donut cushion)

•Ambulation: For gas pain / abdominal distension (especially post-C-section).

•Warm compresses: For breast engorgement (before feeding to facilitate let-down).

•Distraction, deep breathing, relaxation techniques, guided imagery

POST-ANESTHESIA CARE (REGIONAL ANESTHESIA)

•Pain relief assessment: pain relief needs may increase as anesthesia wears off

•VS assessment

•Duramorph checks per anesthesia: HR, RR, O2 Sat, sedation scale x 24 hours

•Assess and treat side effects: N/V, itching, over-sedation etc.

•Post regional and general: Incentive Spirometer/Deep breathing

•Motor/sensory function: Monitor for return of sensation and motor function before allowing ambulation. Patient should be able to lift legs against gravity and feel touch.

•Level of sensory block: Check dermatome level. Document progression of sensory return.

•Blood pressure: Risk of hypotension from sympathetic blockade. Monitor frequently. Treat with IV fluids and positioning (elevate legs if hypotensive).

•Urinary retention: Regional anesthesia decreases sensation of bladder fullness. Assess for distension. Catheterize if unable to void.

Spinal Headache (PDPH — Post-Dural Puncture Headache)

•Characteristics: Severe, positional headache — worsens when upright, improves when supine. Typically posterior/frontal. Caused by CSF leak through the dural puncture site.

•Treatment: Bed rest (supine), hydration (oral and IV), caffeine (oral or IV), analgesics. If conservative treatment fails: epidural blood patch (autologous blood injected into epidural space to seal the puncture).

Epidural Site Assessment

If the patient has had an epidural during labor, assessment of the epidural wound site is important as well as checking for any side effects of the medication injected such as itching, nausea and vomiting, or urinary retention.

Visual inspection of the epidural site and an accurate documentation of intake and output are essential.

Nursing Care: Perineal Trauma

-Ice packs (or cold sitz): 1st 24 hours

-Peri-bottle with every void. Warm water rinse to perineum after voiding/BM — squirt front to back. Pat dry.

-Sitz Bath (warm): after 24 hours

-Pain Control: oral analgesics/benzocaine spray

-Stool softeners/laxatives

-Witch hazel pads (Tucks): Applied to perineum for soothing and astringent effect

What is the recommended care for perineal trauma during the first 24 hours?

Ice packs or cold sitz baths

An ice pack is commonly the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration.

An ice pack can minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site.

Applied intermittently for 20 minutes and removed for 10 minutes.

Peribottle

Is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.

What is the recommended care for perineal trauma after the first 24 hours?

Sitz bath

Sitz Bath

Within the first 24 hours, a sitz bath with room-temperature water may be prescribed and substituted for the ice pack to reduce local swelling, promote muscle relaxation, and promote comfort for an episiotomy, perineal trauma and other wounds, inflammation, hemorrhoids, and anorectal infections.

Nursing Interventions Bowel Function

•Encourage ambulation (promotes peristalsis)

•Adequate fluid intake

•High-fiber diet

•Stool softeners (docusate sodium)

•Assess bowel sounds each shift

•First BM expected by day 2–3. If no BM by day 3, may need laxative or suppository.

•Reassure patient that defecation will not disrupt sutures or cause perineal damage

What are the dietary recommendations for postpartum GI health?

Diet high in fiber, encourage normal food intake, and hydration

When Should Bowel Movement Return By?

By day 5.

Nursing Interventions Urinary Function

•Encourage voiding every 2–4 hours.

•Assist patient to void following delivery. Measure first void volume — should be ≥300 mL to indicate adequate emptying.

•Pain relief & Edema/trauma: ice, analgesia, sitz bath, topical spray

•Bladder scanner; Catheterize if unable to void, if voiding small amounts (<150 mL), or if bladder is distended.

•Assess for "urinary disturbances": Assess for UTI symptoms (dysuria, frequency, urgency, cloudy/foul-smelling urine, fever). Decreased sensation of full bladder, Pai, Edema/trauma.

•Assess for fundal displacement

•Encourage normal p.o. intake

•Use running water, warm water over perineum, or privacy to facilitate voiding. Peppermint essential oil in toilet water

What is the minimum volume expected for the first void following delivery?

300 mL

Assisting With Elimination: Bladder

The bladder is edematous, hypotonic, and congested immediately postpartum.

Consequently, bladder distention, incomplete emptying, and the inability to void are common.

A full bladder interferes with uterine contraction and may lead to hemorrhage because it will displace the uterus out of the midline.

If the patient has difficulty voiding, try: pouring warm water over the perineal area, hearing the sound of running tap water, blowing bubbles through a straw, taking a warm shower, drinking fluids, providing them with privacy, or placing their hand in a basin of warm water.

If these actions do not stimulate urination within 4 to 6 hours after giving birth, catheterization may be needed.

Postpartum Danger Signs

1. Fever >100.4°F (38°C)

2. Foul-smelling lochia or an unexpected change in color or amount

3. Large blood clots or bleeding that saturates a peripad in an hour

4. Severe headaches or blurred vision

5. Visual changes, such as blurred vision or spots, or headaches

6. Leg pain, redness, warmth (signs of DVT); Calf pain with dorsiflexion of the foot

7. Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites

8. Dysuria, burning, or incomplete emptying of the bladder

9. Chest pain, dyspnea (signs of PE — EMERGENCY); Shortness of breath or difficulty breathing without exertion

10. Depression or extreme mood swings

Danger Signs for Mood Changes

•Persistent sadness beyond 2 weeks — suggests PPD, not just baby blues

•Difficulty bonding with infant

•Hallucinations, delusions, bizarre behavior — suggests postpartum psychosis: PSYCHIATRIC EMERGENCY. Do not leave patient alone with infant.

[NCLEX PEARL] Postpartum psychosis is a psychiatric emergency. If a patient reports seeing/hearing things or expresses bizarre thoughts about the baby, intervene immediately — ensure safety of mother and infant, notify provider STAT.

Teaching about Postpartum Blues

1. Transient emotional disturbances

2. Characterized by anxiety, irritability, insomnia, crying, loss of appetite, and sadness

3. Symptoms usually begin 2 to 4 days after childbirth and resolve by day 8(textbook says symptoms "usually arise within 7 to 10 days after childbirth.")

4. Blues typically resolve with restorative sleep

5. Postpartum depression and psychosis are more serious and require professional referral

What are the symptoms of postpartum blues?

Anxiety, irritability, insomnia, crying, loss of appetite, and sadness

When do symptoms of postpartum blues typically begin and resolve?

Begin 2 to 4 days after childbirth and resolve by day 8 (textbook says symptoms "usually arise within 7 to 10 days after childbirth.")

What is the primary resolution for postpartum blues?

Restorative sleep

What is the caloric increase recommendation for breast-feeding mothers?

400+ kcal/day

Nutrition for the Breastfeeding Person

Calories: +400 kcal/day for the first 6 months, then +380 kcal/day thereafter

Calcium: 1,000 mg daily (adolescent females 1,300 mg daily); for example, consuming four or more servings of milk

Iodine: 290 mcg daily; if using salt, make sure it is iodized, and increase intake of kale and cruciferous vegetables

Omega-3 fatty acids: 200 to 300 mg daily; for example, two servings of low-mercury fish weekly

Fluid: It is recommended to drink when thirsty; keep a bottle of healthy liquid nearby

General nutrition recommendations for the postpartum person.

Eat a wide variety of foods with high nutrient density

Minimize or avoid processed foods

Make sure all foods are well cooked to prevent bacterial ingestion

Avoid high-fat fast foods

Eat protein-rich foods, such as soups and stews made with bone broth

Eat plenty of fruit and vegetables—select a variety of colors

Incorporate whole grains into diet such as oatmeal, quinoa, brown rice, and farro

Drink plenty of fluids daily

Avoid fad weight reduction diets and harmful substances such as alcohol

Avoid excessive intake of fat, salt, sugar, and caffeine

Eat the recommended daily servings from each food group

People Who Should Not Breastfeed

Certain people should not breastfeed, including those:

1. Taking illicit drugs such as opioids, cocaine, or PCP (note: people stable on methadone may breastfeed)

2. With HIV infection who are not on antiretroviral therapy and achieving viral suppression

3. With active herpes infections on their breast (should not breastfeed from the affected breast)

4. Whose newborn has galactosemia

5. With mpox or brucellosis infection

6. With active tuberculosis or varicella infection (though expressed breast milk may be fed to the infant) (CDC, 2023a)