The client is a 23-year-old female, G1P1T1A0L1, who delivered a healthy baby 4 hours ago. Delivered a female, at 3650 grams- spontaneous vaginal delivery with forceps, due to shoulder dystocia requiring vacuum and forceps. The patient had a midline episiotomy with 1st-degree tear. Labour lasted 13 hours. Morphine 2.5 mg was given 5 hours ago. EBL less than 250ml, PV loss moderate rubra – wearing pad. The patient has ambulated to the bathroom once for 200cc of urine. Breastfeeding initiated. Her partner just went home to shower and change. The client has been transferred from labour and delivery to the postpartum unit. You are the assigned nurse who needs to complete the initial patient assessment. The newborn is in the nursery for assessment and the first bath at the mother’s request. Use a course textbook on maternity nursing and read the material regarding post-partum health assessment. The following 3 texts could be used by your nursing faculty as a course resource, only 1 of the 3 is required:
Use a course textbook on maternity nursing and read the material regarding post-partum health assessment. The following 3 texts could be used by your nursing faculty as a course resource, only 1 of the 3 is required:
Evans, Robin, et al., (2021). Canadian maternity, Newborn and Women’s Health Nursing: Comprehensive Care Across the Lifespan. Wolters Kluwer
[Background music begins as the camera shows a tranquil postpartum unit. The nurse, Sarah, enters the room with a smile.]
Sarah (Nurse):** Congratulations on the arrival of your beautiful baby girl! I’m Nurse Sarah, and I’ll be taking care of you during your postpartum stay. Today, I’ll be conducting a comprehensive assessment to ensure both you and your baby are doing well after the delivery. Let’s get started!
Sarah:** First, I’ll begin by reviewing your medical history and the details of your recent delivery. You delivered a healthy baby girl weighing 3650 grams, with a spontaneous vaginal delivery using forceps due to shoulder dystocia. You also had a midline episiotomy with a 1st-degree tear. Is there anything else you’d like to share about your labor and delivery experience?
Patient: No, that pretty much sums it up.
Sarah: Alright, let’s check your vital signs, including your blood pressure, heart rate, respiratory rate, and temperature. I’ll also assess your abdomen for any signs of tenderness or distension.
[Camera shows visuals of the nurse checking the patient’s vital signs and performing a gentle abdominal examination.]
Sarah: Your vital signs are stable, and your abdomen looks good. Now, let’s check your lochia. You mentioned having moderate rubra, is that still the case?
Patient: Yes, but it’s not too heavy.
Sarah: Great, I’ll continue to monitor the amount of lochia you’re having. Please let me know if it increases or if you have any clots larger than a golf ball. We want to make sure your postpartum bleeding remains within normal limits.
Sarah: You mentioned that you’ve already ambulated to the bathroom once and passed 200cc of urine. That’s excellent! Make sure to continue drinking plenty of fluids to stay hydrated, especially if you’re breastfeeding.
Sarah: How are you feeling in terms of pain? Are you experiencing any discomfort from your episiotomy or perineal tear?
Patient: It’s a bit sore, but I took the morphine earlier, and it helped.
Sarah: I’m glad to hear the morphine provided some relief. Now, let’s talk about breastfeeding. It’s wonderful that you’ve initiated breastfeeding with your baby. I’ll be here to provide guidance and support throughout your breastfeeding journey. If you have any questions or need assistance, don’t hesitate to ask.
Sarah: Lastly, I want to ensure your emotional well-being. The postpartum period can be overwhelming, so remember to get plenty of rest when you can. If you ever feel anxious or down, know that it’s entirely normal, and we’re here to support you.
Sarah: Thank you for sharing your experiences with me. Your overall postpartum assessment looks promising, and you and your baby are doing well. As your nurse, I’ll be here to provide you with the best care and support during your stay. Remember, if you have any concerns or questions, I’m just a call away. Congratulations once again on becoming a mom!
[Camera fades out as background music continues.]
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