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Maternal Newborn Nursing

Chapter 21

Maternal Newborn NursingChapter 21

Unfolding Case Study

1.

e, g, h

Rationale: The patient’s lochia is heavier than normal due to displacement of the uterus by the bladder, as indicated by the position of the uterus. Massaging the uterus will expel anymore lochia and cause it to become firm. Emptying the bladder will change the lochia and consistency of the uterus to normal expectations. Determining the cumulative QBL will show if the amount of bleeding indicates a postpartum hemorrhage. Administration of pain medication and education are not the priority nursing actions at this time; the priority is adequate perfusion. Insertion of a Foley catheter is an invasive procedure and should not be performed unless the patient is unable to void spontaneously.

2.
Patient Data Data Obtained prior to Nursing Actions New Patient Data after Nursing Actions Effective, Ineffective, or Unchanged
Pain/location 5/uterine cramping 2/uterine cramping a. effective
Location of fundus Deviated to right/2 finger breaths above umbilicus Midline/at the umbilicus a. effective
Consistency of fundus Boggy Firm a. effective
Color of lochia Rubra Rubra c. unchanged
Amount of lochia Saturated peripad and passed two walnut-sized clots Saturated ¼ of the peripad a. effective
Laceration Intact Intact c. unchanged
Perineum Soft, no bruising Soft, no bruising c. unchanged

Rationale: Massaging the uterus and assisting the patient to void are effective, as evidenced by the location and consistency of the uterus, amount of lochia, and decrease in the pain level. The data for the color of the lochia and assessment of the laceration and perineum are the same, therefore, unchanged.

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