Chp15 Postpartum Adaptations

taking-in phase

During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase.

letting-go phase

The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

taking-hold phase

The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?

fundus two fingerbreadths below umbilicus and firm A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

Atony *Uterine Atony *The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

lochia serosa

Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle. Second-degree laceration extends through perineal muscles. Third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall. Fourth degree because it continues through the anterior rectal wall.

When palpating for fundal height on a postpartum woman, which technique is preferable?

placing one hand at the base of the uterus, one on the fundus

Which client should the postpartum nurse assess first after receiving shift report?

the 2-day postpartum client who has a blood pressure of 138/90 mm Hg The postpartum client with a blood pressure of 138/90 mm Hg is showing signs of hypertension and should be seen first to assess for preeclampsia. Preeclampsia can occur during the postpartum period. A pulse rate of 50 bpm and a respiratory rate of 20 breaths/minute are within the normal range. A fever of 100.4° F (38° C) or less during the first 24 hours postpartum is common.

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony _________________________________________________________ hemoglobin level of 12 g/dl (120 g/L) Female 12 or higher Male 13 or higher