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) Fetal heart monitoring:
Nurses are trained to monitor fetal heart rates, interpret patterns, and identify signs of distress, but this task is typically within the scope of a registered nurse's (RN) practice. It may not involve the critical decision-making or advanced skills associated with the highest level of licensure.

B) Taking specimens to the lab:
Taking specimens to the laboratory is a necessary but routine part of care. While it is important for ensuring proper diagnostic testing, it is a lower-level task and does not demonstrate the highest level of nursing practice. This task is often delegated or performed as part of standard nursing duties.

C) Performing vaginal delivery:
Performing a vaginal delivery is a high-level skill that typically requires advanced education, certification, and licensure beyond that of a registered nurse. This is usually performed by a midwife, obstetrician, or other healthcare providers with advanced training and certification. In many settings, a registered nurse may assist with vaginal deliveries but cannot independently perform them unless they have additional certifications (such as Certified Nurse Midwife).

D) Giving a client a bed bath:
While important for patient care and comfort, giving a client a bed bath is a basic nursing task that does not demonstrate working at the highest level of licensure. It is a fundamental nursing activity often carried out by nurses, nursing assistants, or other support staff. The act of providing a bed bath is part of the foundational skill set and does not require advanced knowledge or decision-making that would demonstrate the highest level of practice.

A) At the umbilicus:
After delivery, the fundus is typically located at or just below the umbilicus in the immediate postpartum period, but it will gradually descend over the next few days. By 8 hours postpartum, the fundus is often slightly below the umbilicus, not directly at the umbilicus. The fundus will continue to shrink in size and move downward toward the pelvic region as the uterus contracts and involutes.

B) At a non-palpable depth:
A fundus that is non-palpable is generally expected later in the postpartum period, typically by 10-14 days after delivery, as the uterus contracts and returns to its pre-pregnancy size. At 8 hours postpartum, the fundus is still palpable, generally just below the umbilicus, and should be evaluated for firmness and position.

C) Just above the symphysis pubis:
The fundus is usually higher than the symphysis pubis at 8 hours postpartum, as it is still in the process of descending from the higher position it occupied during pregnancy. It would be expected to be just below the umbilicus or about 1 to 2 finger widths below it. By the second or third day postpartum, the fundus begins to move lower toward the symphysis pubis as it continues to involute.

D) Just below the umbilicus:
Eight hours after delivery, the nurse should expect to palpate the fundus just below the umbilicus. This is a typical finding as the uterus begins to contract and shrink after the delivery of the placenta. The fundus will descend about 1-2 cm per day postpartum, so by 8 hours, it is usually just slightly below the level of the umbilicus.