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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is conducting a physical assessment on a client who is 2 hours postpartum following a spontaneous vaginal delivery. Which of the following findings should the nurse identify as expected physiological adaptations during this period? Select all that apply.

  1. Maternal temperature of 100.2°F (37.9°C)Answer
  2. Reports of strong uterine cramping while breastfeedingAnswer
  3. Maternal resting heart rate of 62 beats per minuteAnswer
  4. D
    Saturating one perineal pad with lochia rubra within 30 minutes
  5. E
    Fundus palpated firmly 2 centimeters to the right of the umbilicus

Answer

The expected physiological adaptations are a slightly elevated maternal temperature (100.2°F or 37.9°C), strong uterine cramping while breastfeeding, and puerperal bradycardia (62 beats per minute).
During the first 24 hours postpartum, a maternal temperature up to 100.4°F (38.0°C) is an expected physiological response to the physical exertion and mild dehydration of labor. Puerperal bradycardia (a resting heart rate of 50 to 70 beats per minute) is also a normal adaptation due to the increased stroke volume resulting from the elimination of placental blood flow. Additionally, uterine cramping, known as afterpains, is expected and often intensifies during breastfeeding because nipple stimulation triggers the release of oxytocin, which promotes uterine involution.

Step-by-Step Solution

1
Analyze the client's clinical timeline.
The client is 2 hours postpartum, meaning the assessment focuses on the immediate transition and early physiological adaptations.
Expected findings change depending on the time elapsed since delivery.
2
Evaluate the vital signs and symptoms for normal physiological responses.
A temperature of 100.2°F (37.9°C), a heart rate of 62 bpm, and cramping during breastfeeding are identified as normal.
Labor exertion causes mild hyperthermia, fluid shifts increase stroke volume leading to bradycardia, and breastfeeding releases oxytocin which causes cramping.
3
Identify findings that indicate potential complications.
Saturating a pad in 30 minutes and a deviated fundus are identified as abnormal findings.
These findings are key warning signs of excessive bleeding and a distended bladder, which increase the risk for postpartum hemorrhage.

Key Concept

Expected Postpartum Physiological Adaptations
Estimated Time:1m 30s
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Topics

Ante/Intra/Postpartum and Newborn Care

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