Preparing for Exam 2 in Maternal–Newborn nursing can feel like a lot, especially when the postpartum period covers so many rapid physical, emotional, and developmental changes. This guide pulls together the essential concepts from Units 4 and 5 to help you study with confidence and understand not just what happens after birth, but why it matters in patient care.
From uterine involution and lochia patterns to postpartum vital signs, parenting behaviors, breastfeeding education, and mental-health considerations, this review is designed to give you a clear, organized breakdown of the topics you’ll see on the exam. Whether you’re reviewing for class, building a care plan, or teaching these concepts to someone else, this summary keeps everything in one place so you can focus on what truly supports safe, effective postpartum care.
Let’s walk through the key points you’ll need to know.
Postpartum Review (Exam 2 – Maternal)
Unit 4: Chapters 18, 19, 20, 21, 24
Unit 5: Chapters 22, 23, 25
Uterine Involution
Involution is the normal process of the uterus returning to its non-pregnant state.
Subinvolution is an abnormal or delayed return.
Key Characteristics & Measurements
- Uterus is midline at the umbilicus within the first 12 hours.
- At 24 hours, the uterus is approximately the size it was at 20 weeks’ gestation.
- Involution progresses at a rate of 1–2 cm per day.
- By 2 weeks postpartum, the uterus is no longer palpable externally.
- Afterpains usually resolve within 3–7 days; breastfeeding increases oxytocin, which strengthens contractions and helps reduce blood loss.
Assessment Reminders
- Firm? Massage to maintain tone.
- Boggy? Massage immediately.
- Deviated? Have the patient void.
- Clots larger than coins? Report.
- Pooling of blood? Assess and report.
Lochia
Normal postpartum vaginal discharge; 1 pad per hour can be normal.
Lochia may continue for 4–8 weeks after birth.
Types of Lochia
- Rubra: bright red; lasts 3–4 days.
- Serosa: pink transitioning to brown; lasts 4–10 days.
- Alba: yellow to white; contains leukocytes, mucus, serum, and bacteria; lasts 2–6 weeks.
When to Report
- Persistent lochia rubra: may indicate retained placental fragments or membranes.
- Persistent serosa or alba with fever, pain, or abdominal tenderness: possible endometritis.
- Offensive or foul odor: suggests infection.
Assessing Lochia: A visual guide to identifying and measuring postpartum blood loss volume on a peripad
- Scant: A 2-inch stain, approximately 10 ml.
- Small: A 4-inch stain, ranging from 10 to 25 ml.
- Moderate: A 6-inch stain, ranging from 25 to 50 ml.
- Large: A stain larger than 6 inches or a saturated pad, representing 50 to 80 ml.
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Clinical Red Flags: When to Worry About Lochia
In the maternal-newborn world, timing is everything. While the image shows us how to measure volume, the rate of that bleeding is what usually dictates our next move.
1. The One-Hour Rule
While "Large" (50 to 80 ml) is a significant amount of blood, the context matters.
- The Red Flag: If a patient saturates a peripad in 1 hour or less, this is considered excessive and is a major warning sign of postpartum hemorrhage.
- The NCLEX Tip: Some textbooks specify that saturating a pad in 15 minutes is the most critical sign of immediate danger.
2. Abnormal Color Progression
Lochia should follow a very specific timeline. If it goes backward, something is wrong.
- Lochia Rubra: Deep red (Days 1–3).
- Lochia Serosa: Pinkish-brown (Days 4–10).
- Lochia Alba: White/Creamy (Day 10 up to 6 weeks).
- The Red Flag: If a patient has progressed to Serosa but suddenly starts seeing bright red Rubra again, it may indicate overexertion or retained placental fragments.
3. The "Clot" Criteria
Small clots (the size of a grape) are common in the first few days, especially when the patient first stands up after breastfeeding or sleeping.
- The Red Flag: Clots larger than a golf ball (or roughly 3 cm) need to be reported. Always encourage students to keep the clots to show the provider for assessment.
4. The "Fleshy" vs. "Foul" Test
- Normal: Lochia should have a "fleshy" odor, similar to a typical menstrual period.
- The Red Flag: A foul or offensive odor is a classic sign of endometritis (infection of the uterine lining), especially if accompanied by maternal fever or uterine tenderness.
5. Fundal Correlation
You can't assess lochia without assessing the fundus.
- The Red Flag: If the bleeding is heavy and the uterus feels "boggy" (soft and spongy), the first nursing action is always fundal massage to encourage contraction and stop the bleeding.
Anatomic & Physiologic Changes During Postpartum Recovery
Hematologic & Metabolic
- Decreased blood volume
- Shifts in estrogen, progesterone, and prolactin levels
Neurological
- Fatigue and general discomfort are common
Renal, Fluid, and Electrolytes
- Increased natriuresis and diuresis
Respiratory
- Decrease in intra-abdominal pressure after birth
Integumentary
- Stretch marks may lighten over time
Cardiovascular
- Increased cardiac output initially
- Ongoing diuresis
Immune
- Elevated WBCs
- Immunizations as indicated: RhoGAM, MMR, Tdap
Reproductive
- Ovulation and menstruation begin returning
Musculoskeletal
- Muscle fatigue
- Possible diastasis recti abdominis
Vital Signs & Laboratory Values
- Temperature: >100.4°F may indicate infection
- Respiratory rate: similar to pre-pregnancy
- Pulse: 50–90 BPM; >100 could suggest bleeding or infection
- Blood pressure:
- Orthostatic hypotension may occur
- Elevated BP may suggest preeclampsia
- Low BP may indicate bleeding
- WBC: >30,000 may indicate infection
- Hemoglobin & Hematocrit: decreased postpartum
- Platelets: 150,000–450,000; <100,000 increases bleeding risk
Parenting Process: Tasks & Responsibilities
- Attachment: mutual acceptance and emotional connection between parent and infant
- Bonding: typically begins immediately after birth (e.g., skin-to-skin)
- Proximity & Interaction: parents learn their baby’s cues and develop familiarity
Dimensions That Support Attachment
- Touch
- Eye contact
- Voice
- Familiar scent/odor
Nursing Care for the Postpartum Woman
Promoting Recovery & Self-Care
- Nourishment: breastfeeding or formula feeding
- Elimination: monitoring bowel and bladder patterns
- Perineal Care: hygiene, medications, ice packs, sitz baths
For Surgical Patients (Cesarean)
- Incision care
- Respiratory assessments during anesthesia recovery
Breastfeeding Education
- Benefits of breastfeeding
- Breast anatomy and lactation physiology
- Latching techniques and the let-down reflex
Ineffective Breastfeeding Concerns
- Sore nipples
- Inverted nipples
- Engorgement
Breastfeeding Management
- Proper collection and storage of breast milk
- Manual and electric expression
- Infant weaning guidance
Formula Feeding Education
- Sterilizing equipment
- Feeding positions
- Formula preparation and safety
Psychosocial Needs After Birth
- Reassurance: builds confidence and understanding
- Emotional support: helps with psychological adjustment
- Monitoring for concerns: difficulty bonding, limited support system, excessive focus on self-image
- Education: safe medication use, postpartum self-care
- Referrals: social services or mental-health support when needed
Postpartum Blues, Depression, and Psychosis
Postpartum Blues
- Usually resolves within a few days to 1 week
- Notify provider if symptoms last longer than 2 weeks
- Signs may include: sadness, anxiety, feeling overwhelmed, crying spells, decreased appetite, and difficulty sleeping
Postpartum Depression
- Can occur anytime within the first year
- Includes symptoms of the baby blues plus more intense or persistent mood changes
- Any thoughts indicating danger to self or baby require immediate medical attention
Postpartum Psychosis
- Very rare, requires urgent care
- Possible signs: hallucinations, confusion, rapid mood shifts, or behavior suggesting risk of harm
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