Question

As the nurse, you admit Margarite Sanchez to the postpartum unit at 10:50 am, and receive the transfer report from Labor and Delivery stating the following:

Patient is a 28 year old G3 P2 Hispanic woman, who gave birth at 8:39 a.m., vaginal delivery with a second-degree laceration.

She received 2 doses of Nubain in labor at 2:15 am, and 4:40 am, for pain relief in active labor.

Both mother and baby are stable.

The mother's bleeding in labor and delivery was moderate.

VS 120/68-72-20-98.2

MS. Sanchez did not void in labor and delivery

Ms. Sanchez nursed her baby for 15 minutes in each breast after the birth.

Jose, her husband, has accompanied her to the unit.

Detail the aspects of initial assessment.

As part of the physical assessment, you discover Margarite's findus is 2cm above the umbilicus and deviated to the left, her lochia is moderate, saturating one-third of the pad during the transfer, and her perineum is swollen.

What are your immediate priorities in nursing care for Margarite Sanchez?

What teaching would you provide at this time, taking into consideration where she is at in the postpartum process?

At 5 hours postpartum, Margarite rates her perineal pain at 6 on a scale of 0-10.

Based on these findings, what is your thought process and identified priority nursing diagnoses?

What interventions are needed at this time?

The next day you are assigned to care for the Sanchez family. Your report from the previous shift indicated that:

Her vital signs were within normal limits.

She voided once during the night.

Her fundus was 1cm below the umbilicus.

Lochia was scant to moderate.

She breastfed her infant twice.

Margarite informs you that she experienced night sweats.

In evaluating these findings what would be your nursing intervention and rationale?

You are anticipating that Margarite will be discharged in the afternoon.

Discuss your plan for discharge teaching, indicating the priority needs.