N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Attachment
(for parent child relationship)
Bonding
Engorgement
Colostrum
Inverted Nipple
Mastitis
Milk ejection reflex-Let down reflex
Involution
Uterine atony – concern on PP
1 MotherBaby/Post Partum
Definitions (List reference – If using Ricci – only need to list page number)
The formation of a relationship between the parent(s) and their newborn through physical and emotional
interactions. Attachment begins before birth and continues throughout the newborn's life. Hormones such
as oxytocin play a role through the chemistry aspect of bonding. This can be enhanced by skin-to-skin
contact, breast-feeding, eye contact, social vocalizations, maternal and milk odors, and newborn
massage during their first postpartum hour. (Ricci, 2017, p. 513).
Bonding is the unilateral attachment of the newborn with the parents that forms within the first 30-60
minutes after birth, which strengthens as parents spend more time with the infant (p. 529). This occurs
through several factors: Kangaroo care (skin-to-skin contact, maternal and milk odors, eye contact, and
breastfeeding (p. 513).
Engorgement is a postnatal physiologic painful condition in which distension and swelling of the breast
tissue occurs at 3-5 days post delivery as a result of an increase in blood and lymph supply, as a
precursor to lactation (p. 632).
Prolactin stimulates the production of milk within a few days after childbirth. This is a creamy, yellowish
nutrient-filled fluid that nourishes the newborn for the first few days of life. Colostrum is rich in maternal
antibodies, especially immunoglobulin A (IgA) which protects the newborn from enteric pathogens. It is
high in minerals and protein as well; unlike later breast milk, colostrum is lower in sugar and fat (p. 72).
Condition in which the nipple, which is normally pointed outward, is pointing inward toward the breast.
Nipple preparation is not necessary during the prenatal period unless the nipples are inverted and do not
become erect when stimulated. Assess for this by placing the forefinger and thumb above and below the
areola and compressing behind the nipple. (p. 408).
Inflammation of the connective tissue/mammary glands in the breast and is common in the first two to
three weeks of lactation. It occurs through stasis of milk from irregular or missed breast-feeding and
trauma caused by poor latching to the nipple (p. 198). It is characterized by fever, increased
warmth/swollen area of affected breast, redness, tenderness, and flu-like symptoms (p. 813).
The Let-down reflex (Aka MER) is a tingling sensation in both breasts that occurs before or during
breastfeeding, caused by the release of oxytocin from the posterior pituitary gland and acting in the
breast (p. 510).
The process of the uterus returning to its normal size through retrogressive changes. It involves
contraction of muscle fibers to reduce those that stretched during pregnancy, catabolism, which shrinks
individual myometrial cells that became enlarged, and regeneration of the uterine epithelium from the
lower layer of the decidua after the upper layers are sloughed off and shed during lochia discharge. For
the first few days postpartum, the uterus shrinks by 1 cm/day; by day 10, it is usually not palpable (p.
502).
This is a serious complication and potentially life-threatening condition that could happen after birth
Complete/Revised 01/2021
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Afterpains
Lochia Rubra
Serosa
Alba
Postpartum Blues
Postpartum Depression
Post Partum Hemorrhage
where the uterus fails to contract after the delivery of the baby-- This is a concern due to primary or early
postpartum hemorrhage (PPH) (p. 501). To check for uterine atony, massage the uterus in order to
stimulate the muscle fibers to contract. If the uterus is not contracted, it will feel soft and “boggy,” as
opposed to firm, as it should be (p. 804). **Urinary retention is a major cause of uterine relaxation; a full
bladder displaces the uterus from the midline and upwards to the right, which inhibits uterine
contraction/involution (p. 506).
Pains after childbirth caused by contractions of the uterus as it returns to its pre-pregnant state. Breastfeeding increases the frequency/intensity of these after pains, as does multigravidy - the muscles of the
uterus contract to reverse the stretching from multiple pregnancies (p. 503).
The 1st stage of lochia: Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that
occurs for the first 3 to 4 days after birth. As uterine bleeding subsides, it becomes paler and more
serous. Should have a fleshy smell (p. 503).
2nd stage of lochia. It is pinkish brown and is expelled 3 to 10 days postpartum. Lochia serosa primarily
contains leukocytes, decidual tissue, red blood cells, and serous fluid (p. 503).
3rd stage of lochia. The discharge is creamy white or light brown and consists of leukocytes, decidual
tissue, and reduced fluid content. It occurs from days 10 to 14 but can last 3 to 6 weeks postpartum in
some women and still be considered normal (p. 503).
Characterized as mild depressive symptoms, anxiety, irritability, mood swings, loss of appetite, difficulty
sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue. This disorder
affects up to 85% of new mothers; it typically peaks on PP day 4 or 5 and resolves prior to two weeks
postpartum (p. 514).
This is a form of clinical depression that can affect women, and less frequently men, after childbirth.
Unlike the postpartum blues, women with postpartum depression feel worse over time, and changes in
mood and behavior do not go away on their own. It is characterized by social withdrawal, anxiety, crying
and increased OR decreased appetite/sleep. Postpartum depression may persist for a minimum of six
months if untreated; it must be treated with medication and counseling! This disorder affects up to 20% of
women in the U.S. and as many as 60% of adolescent mothers; sometimes men are affected (p. 820).
Defined as a blood loss > 500 mL following a vaginal birth or > 1,000 mL after a cesarean birth. Primary
postpartum hemorrhage is blood loss in the above amounts occurring within 24 hours after birth.
Hemorrhaging occurring within 24 hr. to 12 weeks after the birth is termed delayed (late) postpartum
hemorrhage. Both have the potential to cause organ failure and/or death due to lack of blood and
oxygen; occurs in ~ 5% of new mothers (p. 800).
Phases of Maternal Adjustment:
*Briefly describe timing/behaviors for all
Taking In
1st Stage. The Taking-in phase is the time immediately after birth when the client needs sleep, depends
2 MotherBaby/Post Partum
Complete/Revised 01/2021
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
on others to meet her needs, and relives the events surrounding the birth process. This phase is
characterized by dependent behavior. During the first 24 to 48 hours after giving birth, mothers often
assume a very passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse
to make decisions for them concerning activities and care (p. 514).
2nd Stage. The Taking-hold phase is characterized by dependent and independent maternal behavior.
This phase typically starts on the second to third day postpartum and may last several weeks.
As the client regains control over her bodily functions during the next few days, she will be taking hold
and becoming preoccupied with the present. She will be particularly concerned about her health, the
infant’s condition, and her ability to care for her/him (p. 515).
3rd Stage. In the Letting-go phase, the woman reestablishes relationships with other people. She adapts
to parenthood through her new role as a mother. She assumes the responsibility and care of the
newborn, as a unique r and separate being from herself, with a bit more confidence now, thus “letting go”
of her old role (p. 515).
Taking Hold
Letting Go
Postpartum Nursing Assessment
Describe normal assessment findings for each area below for the first 12 hours after birth
Breasts
Uterus
Bladder function
Bowel function



Symmetric with no nodules, lacerations or areas of warmth
No cracked, reddened, blistered, fissured, bruised, or bleeding nipples
Document if the nipples are everted, flat or inverted
Colostrum (creamy yellow) or foremilk (bluish white) may be present ( p. 525).
The fundus should be midline and should feel firm (p. 525).
1-2 hours after birth (between umbilicus and symphysis pubis)
 6-12 hours (level of the umbilicus) - non-palpable by 10- 14 days
Day 1 (fundus is located 1 cm (or 1 fb) below the umbilicus and is recorded as u-1); day 2 as (u-2) (p. 526).
***Have her empty her bladder prior to assessing the uterine fundus.
Within 12 hrs. after childbirth, the MOB should be urinating extensively, as much as 3,000 mL /day or 500 mL+ per void.
She should not be experiencing infrequent/insufficient voiding (<200 mL), discomfort, burning, urgency, or foul-smelling
urine (p. 526).
 Soft, nontender, and nondistended
 Bowel sounds present in all 4 quadrants
 May not experience BM for 1 to 3 days **Offer stool softeners
 Passing gas is WNL (p. 526).
3 MotherBaby/Post Partum
Complete/Revised 01/2021
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Lochia
No foul-smells, large clots, (fist size), or heavy flow (pad is full within an hour = Postpartum Hemorrhage!)
Lochia Classifications:
Scant: 1-2 inch lochia stain (~ 10 mL loss)
Light or Small: ~4” stain (10 – 25 mL loss)
Moderate: 4-6” stain (~ 25- 50 mL)
Large or Heavy: a pad is saturated within 1 hour after changing it (p. 527).
Episiotomy/Perineum No irritation, ecchymosis, tenderness, or hematomas. May have hemorrhoids, slight bruising and edema within the first few
hours, but should not have discharge, redness or edema afterwards. Reassess perineum Q 8hrs for s/sx of infection or
spreading hematoma (pp. 527-528). **Skin should be well approximated if there is an episiotomy site in the perineum or
genital tract laceration (p. 816).
Epidural site
Clean dry and intact. No itching, redness, swelling, irritation or discharge. Look for and ask about any SE such as n/v,
urinary retention, leaking clear fluid (CSF) or blood (p. 528).
Discuss the following relating to infant feeding.
Lactation suppression
Indicators of effective
breastfeeding
(mother/infant)
What would you teach the mother?
Inform mothers who do not plan to breastfeed, that the simplest and safest way to suppress lactation is to let milk
production stop on its own; the use of medications is no longer recommended due to adverse effects (LaFleur, 2020).
Explain that lactation suppression may take 5 to 7 days to accomplish and that it is best to avoid any stimulation to the
breasts, such as warm showers, pumping or massaging the breasts, or sucking.
How to relieve breast engorgement:
 Wear a snug, supportive bra 24 hrs/day
 Take mild analgesics like acetaminophen or ibuprofen
 Ice packs can reduce breast discomfort, swelling, pain
No need to limit p.o. fluid intake; BUT reduce salt intake to decrease fluid retention (p. 547).
Keys to successful breast-feeding include:
 Initiating breast-feeding within the first hour of life, if the newborn is stable
 Placing the newborn on the mother’s chest/abdomen immediately after birth
 Following the newborn’s feeding cues—8 to 12 times in 24 hours
 Providing unrestricted periods of breast-feeding
 Offering no supplement unless medically indicated
 Having a lactation consultant observe a feeding session
 Avoiding artificial nipples and pacifiers except during a painful procedure
 Increasing fluid intake to encourage greater milk production (Evidence-Based Practice Box 18.1)
 Feeding from both breasts over each 24-hour period
4 MotherBaby/Post Partum
Complete/Revised 01/2021
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors

Teaching (frequency,
duration, positioning)
Indicators of effective breastfeeding for the mother
Breast(s) soften during the feed, breasts and nipples feel comfortable and do not hurt (p. 546).
 Watching for indicators of sufficient intake from infant:
o 6 to 10 wet diapers daily
o Waking up hungry 8 to 12 times in 24 hours
o Acting content and falling asleep after feeding
 Keeping the newborn with the mother throughout the hospital stay
 The nurse or lactation consultant should be available to guide and support the breast-feeding mother while on
the postpartum unit (p. 629).
For breastfeeding:
Educate the mother that newborns differ in their feeding needs and preferences, but most breast-fed ones need to be
fed every 2 to 3 hours, nursing for 10 to 20 minutes on each breast. The length of feedings is up to the mother and
newborn.
The four most common positions for breast-feeding are the football hold, the cradling position, across-the- lap position,
and the side-lying position. Each mother, on experimentation, can decide which positions feel most comfortable for her
(p. 625).
For bottle feeding:
Formula-fed newborns usually feed every 3 to 4 hours, finishing a bottle in 30 minutes or less. Daily formula intake for
an infant should be 1.5 to 2 oz/lb of body weight. For positioning, the mother can cradle the newborn in a semi-upright
position, supporting the newborn’s head in the crook of her arm. Holding the newborn close during feeding provides
stimulation and helps prevent choking. Holding the newborn’s head raised slightly will help prevent formula from
washing backward into the eustachian tubes in the ears, which can lead to an ear infection (p. 625).
Signs and symptoms of bladder distention:
A boggy or relaxed uterus = uterine atony. When palpating the area over the symphysis pubis, an empty bladder will not be palpable. Palpation of a
rounded mass suggests bladder distension. When percussing the area, a full bladder is dull to percussion. If the bladder is full, lochia drainage will be
more than normal because the uterus cannot contract to suppress the bleeding (p. 625).
4. Using the REEDA assessment method for perineal and Cesarean Section wound healing, state the term for each letter:
R_Redness = any sign of redness radiating out from the wound
E_Edema = distance edema has persisted beyond the wound
E_Ecchymosis = distance of bruising from wound
5 MotherBaby/Post Partum
Complete/Revised 01/2021
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
D_Discharge = what type of discharge is present: serous, serosanguinous (worse) or sanguinous and/or purulent (worst)
A_Approximation of skin edges = closed/well approximated or separated; if separated, how far apart and what is separated: skin, sub-Q fat
and skin (worse) or skin, sub-Q fat and fascia (worst) (p. 816).
Medications
Analgesics:
Demerol (meperidine)
Dose
Route
50- 100 mg;
May repeat at 13-hour intervals
(Lippincott
Advisor for
Education,
2020)
IM or
sub-Q.
------------------0.1 to 0.2 mg/kg
IV q4h prn
---------IV, PO
Briefly State OB/PP
use
Used to treat
moderate to severe
pain.
(Lippincott, 2020)
--------------------------------
Morphine
Or 15- 30mg
(immediaterelease tablets)
q4h prn
-----------------------------Is used for moderate
to severe pain
(Lippincott, 2020)
Or 10- 20 mg
(oral solution)
q4h prn
(Lippincott,
2020)
Toradol IV (ketorolac)
6 MotherBaby/Post Partum
Complete/Revised 01/2021
Nursing considerations and side effects
-
Incompatible with Morphine
May cause respiratory and CNS depression
Don’t stop medication abruptly; taper the opioid and assess
for s/sx of opioid withdrawal.
- Meperidine is present in breast milk. Monitor newborn for
drowsiness, sedation, feeding difficulties. Can cause newborn
to experience withdrawal effects as well.
- Because of potential side effects to breastfeeding infants, the
mother should discontinue either the medication or
breastfeeding (Lippincott, 2020).
------------------------------------------------------------------------------------------- For IV push, dilute 2.5-15 mg in 4 or 5mL of sterile water;
push slowly. (p. 473)
- For continuous infusion, mix with D5W to yield 0.1-1 mg/mL
- Inspect drug for particulates and color; do NOT use if
particulates don’t disappear upon shaking. After removing
from the ampule don’t use unless the medication is clear or
pale yellow
- Monitor VS (especially BP& RR), pain level, and sedation
level
- May cause CNS and respiratory depression.
- Discontinue slowly and assess for withdrawal
- May be present in breast milk. Monitor newborn for increased
sleepiness, difficulty feeding or breathing, and limpness. Can
cause newborn to experience withdrawal effects.
- Because of potential side effects to breastfeeding infants, the
mother should discontinue either the medication or
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
20-30 mg
(single dose)
Or 30 mg every
6 hours
(maximum=120
mg/day)
(Lippincott,
2020)
---------------------5 mg (initially)
and then if pain
isn’t sufficiently
relieved in an
hour, give 1 – 2
mg
(Lippincott,
2020)
IV
Lortab/ Vicodin
(Hydrocodone/
acetaminophen)
2.5 – 10 mg
(hydrocodone) /
300 - 325 mg
acetaminophen
(Lippincott,
2020)
PO
--------------------------------Hydrocodone
--------------------2.5 to 5 mg Q 4
- 6 hrs
(Lippincott,
2020
----------- -----------------------------PO
Given for moderate to
moderately severe
pain (Lippincott, 2020)
PO
Indications for
---------------------------------Duramorph (long- acting
epidural morphine)
Tylenol #3
7 MotherBaby/Post Partum
Provides short term
pain management and
has antipyretic effects.
Its anti-inflammatory
effects can also help
reduce inflammation
post-partum.
----------- (Lippincott, 2020)
Epidural ----------------------------Is used for moderate
to severe pain and is
given as an epidural
injection
(Lippincott, 2020)
Given for moderate to
moderately severe
pain
(Lippincott, 2020)
Complete/Revised 01/2021
-
breastfeeding (Lippincott, 2020).
Protect from light
Give injection over at least 15 seconds or more.
Monitor HR & BP and educate patient to report signs and
symptoms of bleeding and GI disturbances.
Contraindicated during labor and delivery because may affect
fetal circulation and inhibit uterine contractions
(Lippincott, 2020).
------------------------------------------------------------------------------------------- Maximum total epidural dose should not exceed 10 mg/24
hours.
- Inspect for particulates and discoloration. Don’t use if it’s
darker than pale yellow, discolored, or contains precipitate.
- Store at room temperature until ready to use; discard unused
portion.
- Protect from light; don’t freeze or heat sterilize.
- May cause CNS and respiratory depression.
- Monitor BP.& RR
- Breast feeding mother should either discontinue medication
or breastfeeding (Lippincott, 2020).
Lortab/ Vicodin, and Hydrocodone:
- Wear gloves!
- Use with caution for women pregnant or breastfeeding.
Monitor newborn for poor feeding, diarrhea, irritability,
drowsiness, sedation, tremor, rigidity, and seizures. Can
cause newborn to experience withdrawal effects as well
- May cause slight CNS and respiratory depression
- May cause constipation (Lippincott, 2020).
------------------------------------------------------------------------------------------- Opioid, so may cause Addiction!
- AE: acute airway obstruction, hepatic necrosis, stupor
- SE: N/V/C, dizziness, SOB, fatigue & HA (Lippincott, 2020).
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Acetaminophen/ codeine
Ibuprofen (Motrin)
Acetaminophen
(300 to 325 mg/
dose)
Codeine (7.5 to
10 mg/dose)
(Lippincott,
2020)
200 - 400 mg
PO q4-6h prn
moderate to
moderately severe
pain. (Lippincott,
2020)
Colace/Surfak
PO, IV
80 - 125 mg
(tablets)
(Lippincott,
2020)
PO
50- 360 mg
PO, PR
Or Surfak 240
mg daily until
BM is regular
(Lippincott,
2020)
Provides mild to
moderate pain relief
for post-partum. Also
provides antiinflammatory effects
(Lippincott, 2020)
-
Provides relief of GI
discomfort (gas
retention) (Lippincott,
2020)
-
Provides relief for
constipation (LA for E,
2020)
Pain medication and
post-partum fluid loss
predispose mother to
constipation (Ricci,
2017, p. 538).
-
For PP Hemorrhage:
8 MotherBaby/Post Partum
-
-
Or 400 - 800 mg
IV q6h prn
(Lippincott,
2020)
Simethicone
-
-
-
-
Maximum per 24 hours= acetaminophen 4,000 mg/ codeine
360 mg
Give with food or milk to prevent GI upset
Use with caution for women pregnant or breastfeeding.
Monitor newborn for drowsiness, sedation, feeding
difficulties.
Can cause newborn to experience withdrawal effects as well
Can cause CNS and respiratory depression (Lippincott, 2020)
Give with a meal or milk if PO route.
May cause serious GI disturbances- bleeding, ulcers or
perforation
Drug can cause fetal harm and is contraindicated in
pregnant women starting at 30 weeks’ gestation
Drug may be present in breast milk. Mother should
discontinue medication or breast feeding (Lippincott, 2020).
Drug is not absorbed systematically so it’s safe for pregnant
and breastfeeding women to take.
***Do not confuse with cimetidine.
Educate that changing positions and walking helps pass
flatus (Lippincott, 2020).
Although thought to be compatible with
pregnancy/breastfeeding, the patient should still have a
consultation with the health care provider.
Do not give to patients who are hypersensitive to mineral oils,
the drug, or have intestinal obstruction, or abdominal pain/
vomiting (Lippincott, 2020).
Which ones are contraindicated in which women?
Complete/Revised 01/2021
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
-------------------------------Oxytocin (Pitocin)
--------------------10 - 40 Units in
1L of D5W, LR,
or NSS IV
Also, may
administer 10
Units IM after
delivery of
placenta
(Lippincott,
2020)
----------- -----------------------------IV, IM
Helps in reducing
postpartum bleeding
after expulsion of the
placenta by causing
uterine contractions
(Lippincott, 2020).
------------------------------------------------------------------------------------------- If given via IV, you must dilute the medication and infuse at
a rate needed to sustain uterine contraction and control
uterine atony.
- Use an infusion pump!
- Never administer the medication simultaneously by more than
one route.
- Monitor the HR & BP
- May cause a severe antidiuretic effect and can cause water
intoxication, seizures or death.
- Caution with patients who have had previous cervical or
uterine surgery (including cesarean section)
- Assess uterus to ensure it is contracted.
- Compare amount of blood and check VS every 15min.
(Lippincott, 2020).
------------------------------------------------------------------------------------------- Maximum dose is 2 mg over 8 doses.
- Using a tuberculin syringe, inject deep into the muscle.
Rotate sites if another dose is needed.
- Nausea and vomiting may be severe.
Consider an antiemetic
- Contraindicated in patients with a history of asthma,
hypotension, hypertension, anemia, jaundice, diabetes.
Also contraindicated in those with active cardiac, renal,
hepatic, or pulmonary disease.
- May cause uterine rupture, hypertension, and excessively
elevated temperatures (Lippincott, 2020).
--------------------------------Hemabate
--------------------250 mcg; can
repeat every 15
- 90 min PRN
----------- -----------------------------Deep
Causes uterine
IM
contraction in order to
treat postpartum
hemorrhage from
uterine atony
Methergine
0.2 mg; may be
repeated in five
minutes and
then every 2 - 4
hours (Ricci,
2017, p. 806).
IM
9 MotherBaby/Post Partum
Causes uterine
contractions in order
to treat PPH from
uterine atony and subinvolution (p. 806).
Complete/Revised 01/2021
-
Assess VS, baseline bleeding and uterine tone every 15
minutes
Monitor for HTN, seizures, uterine cramping, N/V, and
palpations
Educate client to report chest pain
Contraindicated in patients who have hypertension,
pregnant women, and breast-feeding women (p. 806).
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Rubella Vaccine
RhoGAM-Rh Immune
Globulin (PP use)
0.5 mL
(RxList)
300 mcg
10 MotherBaby/Post Partum
Sub-Q
Helps establish
injection immunity to Rubella.
(Lippincott, 2020).
Immunity is important
because if mother has
Rubella, it can cause
abnormal brain
development in fetus
(Ricci, 2017, p. 309).
-
IM
-
Women who are Rh
negative who gave
birth to Rh positive
newborn should
receive RhoGAM to
prevent
isoimmunization
(creation of antibodies
that will destroy a
future newborn’s
blood cells) (Ricci,
2017, p. 551).
Complete/Revised 01/2021
-
-
-
-
Wear gloves to prevent risk of infection
Prior to discharge, mothers should be checked serologically
for immunity and given a SubQ injection of the Rubella
vaccine if their titer is less than 1:8 (p. 377).
Need to get a signed consent form!
Should not be given to anyone who is immune compromised,
and mother should be advised to avoid anyone with
undiagnosed rashes (p. 377).
Should not be given during pregnancy (p. 402).
***Mother should be taught to use TWO methods of birth
control for one month following the immunization to avoid
pregnancy b/c the vaccine is teratogenic
2 doses: 1st at 28 weeks gestation and the other within
72 hours after childbirth (p. 551).
Right after delivery, confirm that mother is Rho(D)-negative
and Du-negative by sending a sample of the neonate’s cord
blood for typing and crossmatching. Give drug to mother
only if infant is Rho(D)-positive or Du-positive (LA for E,
2020).
Educate to postpone live virus vaccinations for 3 months after
administration of Rho(D) immune globulin.
Administer at the anterolateral aspect of the upper thigh or
the deltoid muscle of the upper arm.
Consent forms need to be signed (Lippincott, 2020).
RhoGAM is considered a blood product, so Jehovah’s
Witnesses may need spiritual consultation (p. 551).
Updated 1/19
Revised 7/15, 3/16, 5/16 12/16, 12/17, 9/18 bkh
N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Normal Vital Sign
Parameters
Maternal V/S
Infant
LABS








Reference Expected normal findings (Site your reference, If using Ricci – only list page number)
T: Less than 100.4 F (38.0 C)
P: 60 - 80
R: 12 - 20
B/P: should not be higher than 140/90 mm Hg or lower than 85/60 (Ricci, 2017, p. 524).
T: 97.7 – 99.5 F (36.4-37.2 C)
P: 110 - 160
R: 30 - 60 (p. 589)
Expected Normal Findings in Pregnancy Use Appendix A in Ricci for H&H, RBC and WBC.
H&H (CBC)
Blood Type and Rh
HBsAg (Hep B)
RPR/VDRL(Syphilis)
Rubella status
STIs (history or current)
Group B Strep status
Urine dipstick or UA
Physical Assessment/System
Cardiovascular
11 MotherBaby/Post Partum
Hemoglobin: 11.5 – 14 g/dL
Hematocrit: 32- 42%
RBC: 3.75 – 5.0
WBC: 5,000 – 15,000
Blood Type and RH: Rh negative mother needs RhoGAM if she is Rh sensitive to Rh positive baby
HBsAg: result should be Negative to indicate no Hep B infection
RPR/ VDRL: should be Nonreactive (Negative) to indicate no current STIs
Rubella Status: antibodies should be detected to indicate Immunity; a titer less than 1:8 will require
vaccination since this indicates she is Non-immune
- STIs: Negative, but must be treated as appropriate depending on STI
- Group B Strep status: found in ~ 10 - 30% of healthy women; Negative is normal. (p. 481)
- Urine dipstick/ UA: little to no protein on dipstick; no evidence of infection (p. 673)
Reference Expected normal findings (Site your reference, If using Ricci – only list page number)
- Blood volume (which increases during pregnancy) drops rapidly after birth. Will return to normal within four
weeks of postpartum
- Cardiac output decreases to pre-labor values within 24-72 hours postpartum. It rapidly falls in the next two
weeks and returns to normal within 6 -8 weeks. CO returns to prepregnant levels after three months
- Bradycardia is normal (40-60bpm) for up to two weeks following birth.
- Tachycardia (above 100) warrants further investigation. May indicate hypovolemia, dehydration, or
hemorrhage.
- Blood pressure falls in the first two days and increases 3 - 7 days after childbirth. It returns to pre-pregnancy
levels by six weeks
- Woman is at greater risk for blood clots because of reduced fibrinolysis and pooling/stasis of blood at the
lower extremities. Changes return to pre-pregnancy after three weeks.
-
Complete/Revised 01/2021
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Neurological
-
Respiratory
-
Integumentary
Clotting factors remain elevated for 2 - 3 weeks postpartum
Hemoglobin and hematocrit decrease in the first 24 hours, then rise slowly in the next two weeks.
WBCs remain elevated for the first 4 - 6 days post-partum and then fall to 6,000 – 10,000 (p. 505).
Headache may indicate preeclampsia (p. 505).
Assessing pain can also be considered a part of the neurological assessment since the patient’s epidural
medication levels are decreasing and she may need an analgesic (p. 537).
With epidural administration, the lower extremities should also be assessed to determine the degree of motor
and sensory recovery. We can do this by asking if she feels any sensation at different areas that we touch.
The nurse should also observe the woman’s ambulation stability (p. 528).
Diaphragm returns to usual position as the abdominal organs resume their original position, providing relief of
discomforts like SOB/rib aches.
Tidal volume, minute volume, vital capacity, and functional residual capacity return to normal within one
- three weeks postpartum
Rate should be 16 - 24 bpm, with unlabored breathing (p. 507).
RR will return to NL (12-20 bpm) by 1 – 3 weeks as organs return to normal placement (p. 524).
Breath sounds should be clear throughout on auscultation as a result of deep breathing (p. 491).
Musculoskeletal
As estrogen and progesterone levels decline, the darkened pigmentation of the abdomen (Linea nigra), face
(melasma) and nipples fade away.
- Hair loss is common within three months postpartum. This is temporary; normal regrowth returns in four – six
months.
- Striae gravidarum (stretch marks) fade but not completely.
- Diaphoresis in early postpartum occurs to reduce the retained fluids from pregnancy. ***Common at night
especially during the first week (p. 507).
Assess movement of extremities; may have impaired function due to epidural or other medications. Assess frequently
to make sure patient regains pre-birth function. The nurse can do this by asking the woman if she feels sensation at
various areas the nurse touches and also by observing her ambulation stability. Assess range of motion and strength
(p. 528).
Diastasis recti (separation of the rectus abdominis muscles) may be present (from two to four cm). Usually resolves
w/in 6 weeks.
Foot size can remain permanently increased in size. ***Warn pregnant women not to buy expensive new shoes
during pregnancy.
GI
Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone
12 MotherBaby/Post Partum
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
GU
Pain management during and
after delivery:
 Epidural/Spinal
 General Anesthesia
 Duramorph
 PCA
(Demerol/Morphine)
or IV pain meds
 Oral pain meds
 Current pain relief
method and
effectiveness (pain
scale, time of last
medication and
follow-up after
medication)
13 MotherBaby/Post Partum
in the intestines as a result of elevated progesterone levels
Often women are hesitant to have a bowel movement due to pain in the perineal area resulting from episiotomy,
lacerations, or hemorrhoids. Some are fearful that they may “rip their stitches” should they strain.
**Offer any ordered stool softener.
Normal patterns of bowel elimination usually return within a week after birth.
Normal assessment findings are active bowel sounds, passing gas, and a non-distended abdomen (p. 526).
Many postpartum women do not sense the need to void even if their bladder is full. In this situation, the bladder can
become distended and displace the uterus upward and to the right side, which prevents the uterine muscles from
contracting properly (uterine atony) and can lead to excessive bleeding (PPH).
Assess the bladder for distention and adequate emptying after efforts to void. Palpate the area over the symphysis
pubis. If empty, the bladder is not palpable. Palpation of a rounded mass suggests bladder distention. Also percuss
the area: a full bladder is dull to percussion. If the bladder is full, lochia drainage may be more than normal because
the uterus cannot contract to suppress the bleeding (uterine atony).
After the woman voids, palpate and percuss the area again, to determine adequate emptying of the bladder. If the
bladder remains distended, the woman may be retaining urine in her bladder, and measures to initiate voiding should
be instituted (pp. 525 – 526).
During delivery:
Pain perception during labor changes in intensity and nature as labor progresses, and this is associated with
behavioral changes in the laboring woman (p. 464).
Nonpharmacologic measures may include continuous labor support, hydrotherapy, hypnosis, ambulation and
maternal position changes, transcutaneous electrical nerve stimulation (TENS), acupuncture and acupressure,
attention focusing and imagery, therapeutic touch and massage, breathing techniques, and effleurage (p. 465).
Pharmacologic pain relief during labor includes systemic analgesia and regional or local anesthesia (p. 471).
A major focus of care for the woman during labor and birth is assisting her with maintaining control over her pain,
emotions, and actions while being an active participant (p. 477).
Question the woman about her pain; Rate the pain on a pain scale of 0 to 10.
The pain should be controlled/diminished to a tolerable (between 0 to 2) level (p. 465).
After delivery:
Most common practices include nonpharmacologic and pharmacologic measures used in tandem (p. 536).
Question the woman about the type of pain and its location and severity. Have the woman rate the pain using a
numeric scale from 0 to 10 points.
Nursing care should focus on providing comfort measures to ease pain which might include? What 7 interventions?
perineal care, clean gown, mouth care, providing warm blankets, ensuring adequate fluid intake to facilitate healing,
reposition frequently, and encouraging rest between assessments
The goal of pain management is always to have the woman’s pain scale rating maintained between 0 and 2
Complete/Revised 01/2021
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Reproductive
 BUBBLEES
Assessment
Psychosocial
 Family
Interactions/Available
Support Person(s)
points (p. 525).
Ensure you fully document your patients BUBBLEES assessment on Patient Focused Assessment.
Example of normal parameters to expect via assessment:
Positive interactions between woman and SO (lack of verbal abuse, involvement with infant by parents;
demonstration of support/closeness to one another); positive interactions and involvement between parents and
children; involvement as a “family”) See text.
Family Interactions/Available Support Person(s)
Parents’ roles develop and grow when they interact with their newborn. With repeated, continued contact with the
newborn, parents learn to recognize cues and understand the newborn’s behavior. This positive interaction
contributes to family harmony. Assess the parents for attachment behaviors (normal and deviant), adjustment to the
new parental role, family member adjustment, social support system, and educational needs (p. 547).
Ask patient if she has someone to help her when she goes home.
Note Rubin’s stages of transition: “Taking in, Taking hold, and Letting go” – Look up and define for
assessment write up.

Maternal Adjustment
(phase and behavior)
Maternal Adjustment (Rubin’s Stages):
Taking-In Phase: Immediately after birth; when the client needs sleep, depends on others to meet her needs and
relives the events surrounding the birth process. During the first 24 to 48 hours after giving birth, mothers often
assume a very passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse to make
decisions for them concerning activities and care. When interacting with the newborn, new mothers spend time
claiming the newborn and touching him or her, commonly identifying specific features in the newborn, such as “he
has my nose” or “his fingers are long like his father’s” (p. 514).
Taking-Hold Phase: The second phase of maternal adaptation is characterized by dependent and independent
maternal behavior. This phase typically starts on the second to third day postpartum and may last several weeks. As
the client regains control over her bodily functions during the next few days, she will be taking hold and becoming
preoccupied with the present. She will be particularly concerned about her health, the infant’s condition, and her
ability to care for her or him. MOB demonstrates increased autonomy and mastery of her own body’s functioning, and
a desire to take charge with support and help from others. She will show independence by caring for herself and
learning to care for her newborn, but she still requires assurance that she is doing well as a mother. She expresses a
strong interest in caring for the infant by herself (p. 515).
14 MotherBaby/Post Partum
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Letting-Go Phase: The third phase of maternal adaptation occurs when the woman reestablishes relationships with
other people. She adapts to parenthood through her new role as a mother She assumes the responsibility and care
of the newborn with a bit more confidence now. The focus of this phase is to move forward by assuming the parental
role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. She
establishes a lifestyle that includes the infant. The mother relinquishes the ‘fantasy infant’ and accepts the real one
(p. 515).
Positive attachment behaviors/acquaintance:
Positive bonding behaviors include maintaining close physical contact, making eye to eye contact, speaking in soft,
high-pitched tones, and touching and exploring the infant (p. 531).
Makes direct eye contact; assumes “en face” position when holding infant; claims infant as family member, pointing
out common features; expresses pride in infant; assigns meaning to infant’s actions; smiles and gazes at infant;
touches infant, progressing from fingertips to holding; names infant; requests to be close to infant as much as
allowed; speaks positively about infant (p. 532).
Social History
History of Depression
Assessment of past depression with previous pregnancies or depression prior to or during current pregnancy;
depression among other female member of family; “baby blues,” irritability, fatigue- See text .
- Begin the assessment by reviewing the history to identify general risk factors that could predispose a woman
to depression:
Poor coping skills
First pregnancy
Low self-esteem
Numerous life stressors
History of abuse
Mood swings and emotional stress
Previous psychological problems or a family history of psychiatric disorders
Substance abuse
Limited or lack of social support network

Also review the history for specific pregnancy and birth factors that may increase the woman’s risk for depression.
These may include a history of PPD, evidence of depression during the pregnancy, prenatal anxiety, a difficult or
complicated pregnancy, traumatic birth experience, or birth of a high-risk or special-needs infant.
Mother-infant
Attachment
15 MotherBaby/Post Partum
Assess the woman’s activity level, including her level of fatigue. Ask about her sleeping habits, noting any problems
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
with insomnia. When interacting with the woman, observe for verbal and nonverbal indicators of anxiety as well as
her ability to concentrate during the interaction. Difficulty concentrating and anxious behaviors suggest a problem.
Also assess her nutritional intake: weight loss due to poor food intake may be seen. Assessment can identify women
with a high-risk profile for depression, and the nurse can educate them and make referrals for individual or family
counseling if needed (p. 823).

Significant Social
History:
Hx of Depression
S/S of Postpartum
Depression,
Psychosis
S/S of Postpartum Depression
- Postpartum Blues: Many postpartum women (approximately 80%) experience the “blues”. The woman experiences
rapid cycling mood symptoms during the first postpartum week, typically. The woman exhibits mild depressive
symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, despondency, feelings of being
overwhelmed, difficulty thinking clearly, and fatigue. Emotional lability is the most prominent symptom of the
maternity blues. The “blues” typically peak on postpartum days 4 and 5 and usually resolve by postpartum
day 10. Baby blues are usually self-limiting and require no formal treatment other than reassurance and
validation of the woman’s experience, as well as assistance in caring for herself and the newborn. However,
follow-up of women with postpartum blues is important; because up to 20 % go on to develop postpartum
depression (p. 819).
- Postpartum Depression: It affects as many as 20% of all mothers in the United States, and as many as 60% of
adolescent mothers. Unlike the postpartum blues, women with postpartum depression feel worse over time, and
changes in mood and behavior do not go away on their own. Postpartum depression may persist for a minimum of six
months if untreated. Different from the baby blues, the symptoms of PPD last longer, are more severe, and
require treatment.
Signs and symptoms of PPD include feeling the following:
Restless
Worthless
Guilty
Hopeless
Moody
Sad
Overwhelmed
Loss of enjoyment
Low energy level
Loss of libido
The new mother may also:
Cry a lot
Exhibit a lack of energy and motivation
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Be unable to make decisions or focus
Lose her memory
Experience a lack of pleasure
Have changes in sleep or weight
Shows a lack of concern for herself
Withdraw from friends and family
Have pains in her body that do not subside
Feel negatively toward her baby
Experience appetite disturbances
Have feelings of isolation from others
Lack interest in her baby
Worry about hurting the baby
Act detached toward others and infant
Have recurrent thoughts of suicide and death (p. 820).
Postpartum Psychosis: Postpartum psychosis is an emergency psychiatric condition, can result in a significant
increased risk for suicide and infanticide. Symptoms of postpartum psychosis, such as mood lability, delusional
beliefs, hallucinations, and disorganized thinking, can be frightening for the women who are affected and for their
families. It generally surfaces within three months of giving birth and is manifested by sleep disturbances,
fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt
and worthlessness. Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations,
extreme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, disorientation,
depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself and the infant.
The mother frequently loses touch with reality and experiences a severe regressive breakdown, associated
with a high risk of suicide or infanticide (p. 822).
EPDS score and
meaning (Document on
Patient Focused
Assessment Form)
EPDS Score/Meaning: Edinburgh Postnatal Depression Scale. The EPDS is a self-report, quick, and easy
screening tool for PPD that consists of 10 questions with four possible responses. The couple fill out the tool
according to their symptoms during the past 7 days, with each response given a score of 0 to 3 points, creating a
maximum score of 30. Using a cutoff score of 9 or 10, the sensitivity is 86%; the specificity, 78%; and positive
predictive value is 73% (p. 821).
Assessment of substance use/abuse: Legal (caffeine, nicotine) or illegal during past or current pregnancies; other
family members use of substances-- See text.
Substance Abuse
Early detection through a comprehensive evaluation is essential to improve overall treatment outcomes. New
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
Substance Use/Abuse
research supports screening all pregnant women for substance abuse. A major role of the nurse is to focus
on prevention by educating all women about the dangers associated with misuse of prescription
medications. Community education is vital to manage risks to prevent problems from developing (p. 746).
***Complete a thorough history and physical examination to evaluate a client for substance use and abuse.
Substance abuse screening in pregnancy is done to detect the use of any substance known or suspected to exert a
deleterious effect on the client or her fetus. Routinely ask about substance abuse with all women of childbearing age,
informing them of the risks involved, and advise them against continuing. Screening questionnaires are helpful in
identifying potential users, may reduce the stigma of asking clients about substance abuse, and may result in a more
accurate and consistent evaluation (p. 747).
Caffeine
The effect of caffeine intake during pregnancy on fetal growth and development is still unclear. A recent study found
that caffeine intake of no more than 300mg/day during pregnancy does not affect pregnancy duration and the
condition of the newborn (p. 745).
Nicotine
Cigarette smoking during pregnancy is the biggest preventable cause of death and illness in women and
infants and is associated with numerous obstetric, fetal, and developmental complications, as well as an
increased risk of adverse health consequences in the adult offspring.
Smoking increases the risk of spontaneous abortion, tubal ectopic pregnancy, preterm labor and birth, fetal growth
restriction, stillbirth, premature rupture of membranes, low fetal iron stores, maternal hypertension, placenta previa,
and abruptio placentae.
The perinatal death rate among infants of smoking mothers is 20% to 35% higher than that of nonsmoking mothers.
***Perinatal and childhood risks associated with mothers’ smoking during their pregnancies include increased risk of
cleft lip and palate, clubfoot, asthma, middle ear infections, SIDS, reduced head circumference, altered brainstem
development, and cerebral palsy. Smoking has also been considered an important risk factor for low birth weight,
SIDS, and cognitive deficits, especially in language, reading, and vocabulary, as well as poorer performances on
tests of reasoning and memory. Researchers have also reported behavior problems, such as increased activity,
inattention, impulsivity, opposition, and aggression (p. 744).
Assessment of emotional, verbal or physical abuse/violence exposure during, after or before pregnancy by
significant other or other family member(s)-- See text
Family Violence
Family Violence
RADAR: (see next page)
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
R – Routinely screen every client for abuse
A – Affirm feelings and assess abuse
D – Document your findings
A – assess for your client’s safety
R – Review options and make referrals
(Ricci, 2017, p. 21).
Assess for IPV and whether patient feels safe at home. Make sure to ask her this when she is alone (p. 276).
Signs of abuse can emerge during pregnancy and may include? What 5 items? poor attendance at prenatal visits,
unrealistic fears, weight fluctuations, difficulty with pelvic examinations, and nonadherence to treatment
(p. 275).
Uncovering abuse in pregnant women requires a consistent and direct approach to every client by the nurse. Multiple
assessments may enhance reporting by enabling the nurse to establish trust and rapport with the woman and identify
changes in her behavior. Once abuse is discovered in a pregnant woman, interventions should include safety
assessment, emotional support, counseling, referral to community services, and ongoing prenatal care (p. 275).
By nurses making home visits, a trusting relationship can be established between the client and nurse. By addressing
factors that may increase the risk of IPV in general, such as stress as well as other contributing factors, IPV can be
reduced and the cycle of violence can be broken (p. 275).
History of mood and anxiety disorder-- See text
Other Mental Health Issues
Mood Disorders:
Postpartum – Baby Blues, Postpartum Depression, Postpartum Psychosis (stated above).
Anxiety Disorders (Could not find in Ricci or ATI).
Assess history of anxiety disorders. Use open-ending questions and therapeutic communication to get an honest
response from mother. Non-judgmental tone to build rapport with patient. Follow up with physician and determine a
treatment plan specific for the patient. (Christian Mach, UTASN, 2020).
Culture
19 MotherBaby/Post Partum
COMMENT TO SPECIFIC AGE AND CULTURAL DIFFERENCES OF YOUR PATIENT (e.g. Latina, African
American, adolescent)
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N4441 Nursing of the Childbearing Family
Mother Baby/Postpartum Unit
This prep sheet was completed by previous students in N4441 with additions and modifications by N4441 Clinical Instructors
References for Prep Sheet
LaFleur, E. (2020). Lactation suppression: Can medication help? Retrieved from https://www.mayoclinical.org/healthy-lifestyle/
Labor-and-delivery/expert-answers/lactation-suppression/faq-20058016.
Ricci, S. S. (2017). Essentials of maternity, newborn, and women’s health Nursing. (4th ed.). China: Wolters Kluwer Health/ Lippincott
Williams & Wilkins.
Lippincott Advisor for Education. (2020). Wolters Kluwer Health/Lippincott, Williams & Wilkins. Retrieved from
https://advisor-edu.lww.com/lna/home.do
RxList. (2008). Retrieved from https://www.rxlist.com/meruvax-drug.htm#description
20 MotherBaby/Post Partum
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