A nurse on a postpartum unit is caring for a client.

Exhibits

Click to highlight the findings that require follow-up.

To deselect a finding, click on the finding again.

Nurses' Notes

2hr postpartum:

Client is 2 hr postpartum following vaginal delivery. Client alert and oriented. Lungs clear to auscultation bilaterally. S1 S2 auscultated, no murmur. Abdomen soft, nontender. Uterus firm and midline, 1 cm below the umbilicus. Moderate amount of lochia rubra present on perineal pad.

24 hr postpartum:

Client alert and oriented. Lungs clear to auscultation bilaterally. S1,S2 auscultated, no murmur. Abdomen soft, nontender. Uterus boggy and midline, 2 cm below the umbilicus. Moderate amount of lochia rubra present on perineal pad, foul odor present.

Vital signs:

1 hr postpartum:

Temperature 37.5° C (99.5° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 118/78 mm Hg

24 hr postpartum:

Temperature 38.3° C (100.9° F)

Heart rate 105/min

Respiratory rate 18/min

Blood pressure 115/78 mm Hg

A) Contractions that increase in intensity:
This is a hallmark sign of true labor. In true labor, contractions become progressively more intense, frequent, and regular. They also do not subside with rest or changes in activity. The intensity of contractions gradually increases as the cervix dilates and effaces, signaling the onset of labor.

B) Leakage of fluid from the vagina:
Leakage of fluid from the vagina, particularly if it is clear and odorless, is indicative of rupture of membranes, which can occur in true labor. If the membranes rupture and there is a continuous leakage of fluid, it is important for the client to contact the healthcare provider as it may signal the onset of labor. This is a significant sign of labor, especially if accompanied by contractions.

C) Increased bladder pressure:
Increased bladder pressure can occur in pregnancy, especially as the uterus grows and presses on the bladder. However, bladder pressure alone is not a definitive sign of true labor. It can also be a common complaint during late pregnancy, even before labor begins. This symptom would not be specific to true labor.

D) Blood-tinged vaginal mucus:
A bloody show, or blood-tinged mucus, is another classic sign of true labor. This happens as the cervix begins to soften, dilate, and efface, causing small blood vessels in the cervix to break. The bloody show is typically a pink or brownish mucus discharge and can occur just before labor starts, signaling that the cervix is changing in preparation for delivery.

E) Uterine contractions that decrease with rest:
This is a characteristic of false labor (Braxton Hicks contractions). In false labor, contractions tend to decrease or stop when the woman changes position, rests, or hydrates. On the other hand, in true labor, contractions persist and increase in intensity and frequency even with rest or hydration. Therefore, this is not a sign of true labor.

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.