RLE WEEK 11

Cindy is a G2P2 who delivered a baby boy via normal

spontaneous delivery 6 hours ago. She is admitted to the
maternity ward. Initial assessment reveals the following data: T
37.2 deg C, pulse 70 bpm, respirations 18 cpm, blood pressure
110/70 mmHg, fundus slightly soft and located to the right of
the umbilicus, lochia moderate, midline episiotomy intact with
slight edema.

1. What is your interpretation of these data?

According to the interpretations, Cindy has a somewhat low
pulse and blood pressure. Furthermore, even six hours after
delivery, the fundus is still slightly soft and to the right of the
umbilicus. However, by about an hour after delivery, the fundus
should typically be firm and at the level of the umbilicus. She is
also exhibiting a little edema following the episiotomy. Cindy
has a somewhat constricted fundus to the right of the
umbilicus, most likely because of a full bladder. Her multiparity
and multiple pregnancies increase the risk of postpartum
hemorrhage.

 1. What is your first intervention? Why? What would be your next

intervention?
Edema may result from bacterial infections. As a result, as part of my
intervention, I will prescribe the antibiotics Amoxicillin and clavulanate
(Augmentin, Augmentin XR, Amoclan). Amoxicillin binds to penicillin-
binding proteins and stops bacteria from making cell walls by attaching to
those proteins. The inclusion of clavulanate inhibits bacteria that produce
beta-lactamase. It is an effective alternative antibiotic for people allergic
to or intolerant to the macrolide class.
The fundus must be in the middle of the symphysis pubis and umbilicus
one to two hours following delivery. This client's fundus is soft and
deviated to the right, which suggests "Atony of the uterus," which is
worrying.
Painful muscular contractions might happen as the uterus returns to its
regular size. Treatment for this involves uterine massage. The HCP
squeezes the uterus through the abdominal wall with one hand on the
perineum and the other on the uterus. After a natural delivery or abortion,
this decreases uterine cramping and bleeding.
- It is possible to provide uterotonic drugs such as oxytocin,
methylergonovine (Methergine), and prostaglandins like Hematite. The
client will be able to recover from uterine atony since the uterus will
transform from flexible to hard and will be aligned with the umbilical
cord.
 1. What should you immediately teach
Cindy?
Massage the enlarged fundus, give Pitocin,
or have the patient breastfeed to help it
tighten up. The woman should empty her
bladder first since a full bladder may
contribute to the soft fundus because it
inhibits uterine contractions. Next,
massage the uterus until it becomes firm.
Cindy is worried about constipation because she
experienced the same problem after her previous childbirths
and has
been constipated during the last months of this pregnancy.

1. What interventions and teachings can you advise Cindy

to avoid constipation?
-Drink plenty of water and other hydrating liquids
-Eat some berries
-Take some laxative that the doctors prescribe.
-Increasing your fiber intake: Foods high in fiber, such as
whole grains, fruits, and vegetables, enhance gut health. If
you have gastrointestinal sensitivity, avoid high-fructose
fruits that can induce gas, such as apples, pears, and
melons.
-Increasing your physical activity: Exercising regularly can
maintain your colon healthy.
On Day 3 postpartum, Cindy’s fundus is in the midline, firm, and 1
cm below the umbilicus.

1. Are these assessments normal? Why or why not? If they are

normal, what is the explanation for these findings?
Cindy's fundus and episiotomy results are abnormal. One or more
of the following conditions, such as placental abruption, placenta
previa, an enlarged uterus, numerous pregnancies, preeclampsia,
having given birth frequently in the past, protracted labor, or
infection, maybe cause a soft and tender fundus. One to two hours
after delivery, the fundus is typically halfway between the umbilicus
and symphysis, one centimeter above or at the level of the
umbilicus 12 hours later, and about three centimeters below the
umbilicus by the third day. For edema in episiotomy, bacterial
infections may cause swelling. On Day 3, after giving birth, Cindy's
fundus, on the other hand, is still in the midline, firm, and 1 cm
below the umbilicus. She should be given oxytocin to maintain
uterine contraction and manage hemorrhage.
2. What kind of lochia should the nurse expect Cindy to
have at this time?
The vaginal discharge that follows a vaginal delivery is
known as Lochia. It has a foul, musty stench-like menstrual
discharge. For the first three days after delivery, Lochia is
dark crimson in hue. In Cindy's situation, swelling and
edema may lead to numerous blood clots, some of which
may be larger than a plum.The borders of Cindy's
episiotomy are closely approximated; there is no edema,
bruising, or drainage. Cindy's episiotomy has a mild
reddening along the suture line.
Cindy’s episiotomy is slightly reddened along the suture
line; the edges are closely approximated, and there is no
edema, bruising, or drainage.

1. How would you interpret these findings? What nursing

actions are appropriate?
The results demonstrate that Cindy's episiotomy was
normal since there is no edema, bruising, or drainage, and
the suture line is only mildly discolored. The edges are
also closely approximated. Nursing interventions that are
suitable for Cindy's circumstance include being available
at all times, assisting in the creation of a routine, teaching
and providing advice on newborn and self-care, providing
assistance with breastfeeding, providing advice on
hygiene maintenance, assisting Cindy in rest and recovery,
and assisting in the integration of the child into Cindy's
family.