DYNCM107 CARE OF MOTHER, CHILD, ADOLESCENT

(WELL CLIENTS)

Case Study 113

Name __Princess Levie Ceniza__________Class/Group BSN 2A_group 1_

INSTRUCTION. All questions apply to this case study. Your responses should be brief and to the point. When
asked to provide several answers, list them in order of priority of significance. Do not assume information that
is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will
need to rewrite it.
SCENARIO
T.N. delivered a healthy male infant 2 hours ago. She had a midline episiotomy. This is her sixth pregnancy.
Before this delivery, she was para 4014. She had a epidural block for her labor and delivery. She now admitted
to the postpartum unit.

1. What is important to note in the initial assessment?

Vital signs : Blood pressure might be low because of epidural; temperature might be slightly
elevated because of exertion. With an epidural, the client has an IV line, so dehydration should not
be a concern.

Fundal height and position: This patient might have an enlarged fundus because of multigravida
status. The baby's size might also be a factor.

Lochia: This might be more profuse for a multigravida and if fundus feels boggy. It should be rubra
in color.

Episiotomy: Assess for swelling, discoloration.

Urinary output: She should void in 6 to 8 hours. Encourage fluid intake to promote voiding, and
assess for urinary tract infection symptoms.

Bowel elimination: This might be sluggish for a few days. Stool softeners may be needed. Should
avoid straining.

Lower extremities: Blood pooling or clots might occur. Assess for unilateral calf swelling and
tenderness.

Breasts: For tenderness and tightness, she might need warm packs or ice packs if electing not to
breastfeed.

Assess for afterpains: The uterus is contracting—it works harder with successive deliveries. If the
 woman is breastfeeding, oxytocin is released more frequently.

Emotional status: Assess T.N.'s feelings post-delivery. Inquire whether she has any questions or
concerns regarding her physical or emotional well-being. Remind her that it is important for her to
also care for herself and not just her infant. This is her fifth child; inquire about her support system
after discharge.

2. You find a boggy (spongy / flaccid) fundus during assessment. What corrective measures can be
instituted?

Massage uterine fundus until firm. If it does not remain firm, additional oxytocin can be given as
ordered. Assess for a full bladder, which can prevent the uterus from contracting normally.

3. The patient complains of pain and discomfort in her perineal area .how will you respond?

Inspect her perineum and the episiotomy site.

Apply ice bag to perineum, use topical anesthetic spray, and give pain medications as ordered.

Encourage sitz baths using cool water for the first 24 hours to decrease edema and warm sitz baths
after 24 hours to promote circulation and healing.

4. The nurse reviews the hospital security guidelines with T.N. the nurse points out that her baby has
special identification bracelet that matches a bracelet worn by T.N. and reviews other security
procedures. Which statement by T.N. indicates a need for more teaching?
a. “ If I have a question about someone’s identity, I can ask about it”
b. “If someone comes to take my baby for an exam, that person will usually carry my baby to the exam
room”.
c. Nurse on this unit all wear the same purple uniforms”.
d. “Each staff member who takes my baby somewhere should have identification picture badge”.

It is essential to teach new parents about the importance of checking the identity of any person
who comes into the room to remove the baby. Picture identification badges should be checked,
and often unit staff members will wear matching uniforms. If a baby is to be taken from the
mother's room to another location, the baby is usually wheeled in a bassinet, not carried in a staff
member's arms.

5. An hour after admission, you recheck T.N.’s perineal pad and find that there is a very small amount of
drainage on the pad. What will you do?
 a. Ask T.N. to change her perineal pad
b. Check her perineal pad again in 1 hour
c. Check the pad underneath T.N.’s buttocks = for leakage
d. Document the findings in T. N.’s medical record.

When assessing for postpartum bleeding, it is important to check underneath the woman's
buttocks. Blood may flow between the buttocks onto the linens under the mother, and excessive
bleeding might go undetected if this area is not also checked.

6. That evening assess TN’s V/S. which vital signs would be of concern at this time?

The elevated pulse (tachycardia) and the hypotension (low blood pressure) may suggest
hypovolemia, possibly because of excessive bleeding. During the first 24 hours of the postpartum
period, the temperature may rise slightly, but a temperature elevation is not of concern unless it
exceeds 100.4° F (38° C). The respirations are within the normal range.

7. What will you do next?

Assess for signs of excessive postpartum bleeding. Assess the color, amount, and odor of the lochia
and whether there is any blood underneath the patient's buttocks.

Check the uterine fundus and, if it feels boggy, massage it until it feels firm.

Monitor VS closely, and notify provider if BP or pulse does not improve.

8. T.N.’s condition is stable and you prepare to provide patient teaching. What patient teaching is vital
after delivery?

Perineum care: Always wipe from front to back after voiding or defecating; wash perineum with
warm water using a squirt bottle, apply anesthetic ointment or spray as ordered, change peri-
pads frequently, and be careful to wash hands before and after perineum care.

Fluids: Encourage fluid intake for rehydration and to prevent constipation.

Ambulation: Encourage early ambulation to prevent blood clot formation and constipation.

Feeding: Facilitate infant feeding.Newborn care

Danger signs: Excessive bleeding and signs and symptoms of infections (chills, fever over 100.4 ° F,
redness of breast or incisions, foul-smelling discharge).

Postpartum exercises: Teach Kegel exercises to strengthen perineal muscles and other exercises to
strengthen abdominal muscles.
 Sexual activity: Without contraception, it is possible to get pregnant again a short time after delivery.
Discuss options for the woman and her partner.

Rest: Adequate rest is very important for health; encourage naps and limiting visitors.

9. T.N. tells you she must go back to work in 6 weeks and is not sure she can continue breastfeeding. What
option are available to her?

The advantages of breastfeeding for babies are well understood, but there are several advantages
for new mothers as well. It is less expensive and less time-consuming because no preparation of
formula is needed.
Assure her that she can continue breastfeeding. Pumps are available and take little time to use.
Breast pumps are designed for single-person use to prevent possible transmission of hepatitis B or
C because they cannot be cleaned and sanitized.
Breast milk can be frozen and given to her baby in a bottle while she is at work.
Babies can be brought to the workplace for feeding if appropriate.
If she wants to stop breastfeeding, she can begin decreasing the number of breastfeedings by
one (and increase the number of bottle-feedings by one) every 2 or 3 days until she breastfeeds
mornings and evenings only, or stops altogether.
Obtain a consultation for a lactation specialist to assist her with her transition back to a work
schedule.

CASE STUDY OUTCOME

T. N. Is discharge to home and plans to consult a lactation specialist before returning to work.