Post Partum Assessment

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Ryan Davis2/28/12

Seton Hall University
College of Nursing
NUTC 3914 Maternal Newborn Nursing

Post Partum Assessment

Mother’s initials: CC
• Age of Mother : 36

• Medications: NKDA
• Food: None
• Environmental: None


Para: 1, Gravinda 4
• Term : 2
• Pre-term : 0
• Abortion : 2
• Living : 2

Age of siblings : 4

Type of delivery
• Normal Spontaneous Vaginal delivery (NSVD) or caesarean-section delivery • Length of labor (if applicable)
• Partner or Spouse available : yes, he is by the mother’s bedside. • Anesthesia (local, spinal, epidural, and/or general) : Elective C- Section • Was this a high-risk pregnancy of labor and deliver? (If yes, explain) : Yes, Mother has Thyroid disease and HPV.

• Sex : Female
• Weight : 6lbs 4onces
• Apgar (1 and 5 minute) : 9-9
• Breast or Bottle-feeding : Bottle

Activity of mother
• Mother is sitting in the chair and feed baby while gazing at her indearly. Diet of mother
• Regular and whole
General postpartum assessment findings
Mom appears to be healthy, comfortable, in no pain, has no complaints or complications.

Vitals Signs
• Temperature : 97.4 Tympanic Temperature
• Pulse : 84, Regular and Full
• Respirations : 22 BPM while talking
• Blood pressure : 112/ 79

• Alert and oriented : Mom is AOx4, Person, Place, Time, Situation • Lethargic
• Restless
• PERRLA : Pupils are Equal Round and Reactive to Light with Accommodation • Behavior


• Maternal newborn attachment (describe): Feeding and holding baby. Smiling and involving family.

• Readiness and receptive behavior for postpartum teaching (describe): Watched video on Post-partum depression.

• Signs of being anxious, depressed, uncooperative, etc. (if present, describe): None present

• Partner or spouse available and/or supportive (if present, describe): Yes, partner is by the mother’s side and actively engaging baby.

• Color (pink, brown, pale, cyanotic, or flushed): Pink • Temperature (warm, hot, or cool): Warm
• Humidity (dry, moist, clammy, or diaphoretic): Dry

• Breath sounds (anterior and posterior): Bilaterally Clear to Auscultation. No stridor, wheezing, rales, ronchi, gurgling or snoring present.

Heart Sounds
• S1 and S2: Present
• Murmur: None present

• Wearing bra: Yes, Supportive

• Soft, filling, firm, engorged, redness, or area of tenderness or discomfort (if present, describe): Breast or filling with no tenderness present.

• Nipples (intact, reddened, sore, cracked, inverted, and/or using breast shields): No cracking, redness, edema, pain, or outwardly signs present. Nipples are intact and healthy appearing.

• Comfort measures used for breastfeeding or non-breastfeeding mother (bra, ice, no stimulation, analgesics, cabbage leaves, tea bags, lanolin cream): None

Newborn feeding (Document mother’s answers in quotes)

1. It is important to feed the baby on demand. Do you know what this means? : Mother understands that it is important to feed her baby when she gets hungry and at regular intervals. 2. Describe how and when to burp the baby. : The baby should be burped at every half once.

3. How do you know the baby is getting enough formula or breast milk? : Because the baby detaches from the nipple and stops sucking.

4. How do you use a breast pump (if applicable)? : The patient had a lactation nurse explain the procedure to her.

5. What does a lactation diet include?
Eat a well-balanced diet for your health, Don't count calories, Aim for slow and steady weight loss, Include a variety of healthy foods, Choose good fats, Take extra steps to avoid contaminants, Eat fish - but be picky, Go easy on the alcohol, Drink plenty of water and limit caffeine, Consider...
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