STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF THE PLACENTA)

STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF THE PLACENTA)...

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STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF  THE PLACENTA) CLIENT ASSESSMENT DATA BASE Activity/Rest May appear “energized” or fatigued/exhausted, sleepy Circulation Pulse usually slow (50–70 beats per minute [bpm], owing to vagal hypersensitivity). Blood pressure (BP) variable; may be lower in response to analgesia/anesthesia, or elevated in response to oxytocin  administration or pregnancy-induced hypertension (PIH). Edema, if present, may be dependent (e.g., confined to lower extremities); or may include upper extremities and facies,  or may be generalized (signs of PIH). Blood loss during labor and delivery up to 400–500 ml for vaginal delivery or 600–800 ml for cesarean birth. Ego Integrity Emotional reactions regarding birth experience varied and changeable, e.g., excitation, disinterest (exhausted), or  disappointment May express concern or apologize for intrapartal behavior or loss of control; may express fears regarding condition of  newborn and immediate neonatal care Elimination Hemorrhoids often present and protruding. Bladder may be palpable over symphysis pubis, or urinary catheter may be in place. Diuresis may occur if pressure of presenting part obstructs urinary flow, and/or intravenous (IV) fluids are  administered during labor and delivery. Flood/Fluid May report thirst, hunger, or nausea Neurosensory Sensation and movement of lower extremities decreased in presence of spinal anesthesia or caudal/epidural analgesia. Hyperreflexia may be present (suggests developing or persistent hypertension, especially in diabetic, adolescent, or  primiparous client). Pain/Discomfort May report discomfort from various sources; e.g., afterpains, tissue trauma/episiotomy repair, bladder fullness, or  feeling cold/muscle tremors with “chills” Safety Slight temperature elevation initially (exertion, dehydration). Episiotomy/laceration repair intact, with tissue edges closely approximated. Perineum free of redness, edema, ecchymosis, or discharge. Striae may be present on abdomen, thighs, and breasts. Sexuality Fundus firmly contracted, midline, and located at the level of the umbilicus Moderate amount of vaginal drainage or lochia, dark red, with only a few small clots at most (up to small plum size)
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Breasts soft, with nipples erect Social Interaction Varied response to infant based on individual expectations, energy level, response of others, and condition of infant Teaching/Learning Various medications may have been administered during intrapartal period (note time and amount). Questions or concerns voiced regarding self/infant care.
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STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF THE PLACENTA)...

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