Maternity Nursing: Postpartum Q 43
When performing a postpartum check, the nurse should:
A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum.
B. Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen.
C. Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation.
D. Wash hands and put on sterile gloves before beginning the check.
Correct Answer: A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum.
While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus. The nurse must be well versed in postpartum assessment and be able to identify subtle changes that could indicate a woman’s deteriorating condition. Components of care should be standardized regardless of whether the recovery is done in a post-anesthesia care unit (PACU), a labor and delivery room, or a postpartum room.
Option B: According to the 2010 recommendations from the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), the nurse caring for the woman should not have any other patient or infant care responsibilities until an initial assessment is completed and documented, the repair of the episiotomy or perineal lacerations is complete and the woman is hemodynamically stable. Assessments during the immediate postpartum period start from the delivery of the placenta and continue for at least 2 hours or until stable. Assessments should be orderly and ongoing so that timely identification can be made of any abnormal changes in the woman’s clinical condition.
Option C: The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate. Assist the woman to empty her bladder. Catheterize only if the woman is unable to void and the bladder is distended. Once the bladder is empty, reevaluate the fundal height. Note the overall appearance of the woman, including skin color, motor activity, facial expression, speech, mood, state of awareness, and interactions with others. Any variation from normal assessment parameters requires reassessment, communication, and early intervention as indicated to prevent potentially serious consequences.
Option D: Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions. Involution is the process of the uterus returning to its prepregnant state. Uterine tone should be assessed at least as frequently as vital signs, every 15 minutes in the first 2 hours.4 Amount of blood loss should be assessed on an ongoing basis during this time. Uterine atony is the most common cause of postpartum hemorrhage, which remains a major cause of maternal morbidity and mortality.