Case 2: A client delivered an infant 3 hours ago.

The nurse assesses the client and

finds the following: fundus firm at 1 centimeter below the umbilicus, small amount of
lochia rubra, midline episiotomy well approximated. The client states she is
“cramping really bad” when she nurses. She has not ambulated since delivery.

a. What else would be important to know about this client?

- The nurses should always check patient’s vital signs every 15mins, make sure
that the patient is comfortable with her position this may help the client to reduces
pain,
vaccines are important this may help to protect mothers from getting sick.

b. The client states she would like to go to the bathroom. What should the nurse do?
- Asses the patient if she would like to go to the bathroom, the nurse should
accompany the clients to the bathroom to empty her bladder also instruct the
mother the proper cleaning of her perineum with proper solution and medication to
her perineal area should be observed, and if unable to urinate ask the patient to go
in bathroom.

c. The client is unable to void. What should the nurse do next?

- The nurse should ask the patient if she wishes to drink water then, let the
patient drink water. If not yet able to void, ask patient for Catheterization.

d. The client’s vital signs are: T 100.8 F, P 56, R 16, BP 110/56. How should the nurse
interpret these findings, and what interventions are indicated?
- Based on the assessment the vital signs are normal, fundus firm at 1
centimeter below the umbilicus, small amount of lochia rubra, midline episiotomy,
while breastfeeding cramping is normal because her uterus contract. However,
the pulse rate and blood pressure are lower than the normal rate (60-100bmp
120/80mmHg). Blood pressure should return to her pre-pregnancy levels after
she gave birth so the nurse should recheck the mother’s blood pressure and
report for large difference or gap between the two rates.
- On the other hand, bradycardia is common during the first 6-10 days after
delivery. The heart rate is 50-70 beats per minute possibly related to:
- Decreased cardiac strain
- Decreased blood volume following placental separation
- Increased stroke

e. What behaviors would the nurse expect to see if this client is bonding positively with her
newborn?
- The nurse will be able to witness how the patient or the mother cares for her
newborn. She will breastfeed her child from time to time and see how happy the
mother with her child is. This also aids in predicting quality of maternal – infant
relationship during subsequent 12 months.

References:
1. https://www.ejog.org/article/S0301-2115(16)30896-X/pdf
2. https://pubmed.ncbi.nlm.nih.gov/11391337/
3.
https://admin.abcaignup.com pdf
Postpartum Physiology, what's normal?

Erika Allyson F. Bedural

Joanna D. Ducut
Ma. Mica Fatima A. Esternon