NCLEX Review Guide: Postpartum Interventions

Vital Sign Monitoring

• Temperature should be assessed every 4 hours and may be elevated up to 100.4°F (38°C) in first 24 hours due to dehydration and exertion.
• Blood pressure monitoring is crucial as hypertension may indicate preeclampsia which can occur up to 6 weeks postpartum.
• Pulse may be bradycardic (50-70 bpm) due to increased stroke volume and is considered normal in absence of other symptoms.

Fundal Assessment

1. Position client supine with knees slightly flexed
2. Place one hand above symphysis pubis for support
3. Use other hand to palpate fundus with fingertips
4. Assess height, firmness, and position

• Fundus should be firm, at or below umbilicus, and midline immediately after delivery.
• Fundus descends approximately 1 cm (one fingerbreadth) per day and should be non-palpable by day 10.

Types and Timeline

• Large clots (>plum size) or saturating >1 pad/hour indicates hemorrhage requiring immediate intervention.
• Foul-smelling lochia may indicate endometritis and requires antibiotic therapy.

Proper Latch Techniques

• LATCH assessment evaluates Latch, Audible swallowing, Type of nipple, Comfort, and Hold/positioning.
• Proper positioning includes tummy-to-tummy contact with infant's ear, shoulder, and hip aligned.
• Signs of adequate intake include 6-8 wet diapers daily, audible swallowing, and appropriate weight gain after day 5.

Common Complications

• Engorgement management includes frequent feeding, warm compresses before feeding, cold compresses after feeding.
• Mastitis symptoms include flu-like symptoms, localized breast pain, and requires continued breastfeeding with antibiotic therapy.

Episiotomy and Laceration Care

1. Assess using REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation)
2. Provide peri-bottle for cleansing after each voiding/bowel movement
3. Apply ice packs for first 24 hours, then warm sitz baths
4. Administer prescribed pain medications and topical anesthetics

• Fourth-degree lacerations extend through anal sphincter and require careful monitoring for infection and healing.
• Teaching includes wiping front to back, changing pads frequently, and reporting signs of infection.