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A patient has finished the third stage of labor and is near completion of the fourth stage for a vaginal delivery. The labor and delivery nurse calls her report to the unit nurse and includes the following information: temperature 37.2°C, heart rate 58, WBC count 16,000. How should the receiving nurse respond?

Explanation

• The fourth stage of labor describes the time from one hour after birth to four hours after delivery when the tone of the uterus is restored with continued contractions from the release of oxytocin. Based on the given assessment, this patient has a heart rate within normal limits for an adult, acceptable labs, and is afebrile.

• Maternal assessments during the fourth stage of labor should occur every 15 minutes for the first hour, and then every 30 minutes for the second hour. If regional anesthesia has been used, additional assessments are required. A woman should never be discharged from the recovery area until completely recovered from anesthesia.

• Routine assessments include: 

Blood pressure and heart rate and regularity

Temperature

Fundus

Bladder (for distention)

Lochia (small to moderate)

Perineum

• In the third stage of labor, after the placenta is expelled (usually 5 to 30 minutes after the birth), maternal bleeding, vital signs, and the fundus are assessed.

• In the fourth stage of labor, the blood pressure and pulse are expected to return to pre-labor levels. Normal heart rate for most adults is generally 60 to 100. Heart rate can vary with age, size, and fitness level, so it is most important to determine if this heart rate is normal for this patient. Uterine massage may be needed, and ice packs can be given for perineal comfort during this stage.

• The patient has no signs of infection and the temperature is WNL. The normal WBC count during the postpartum period may be as high as 30,000.

• The placenta is delivered during the third stage of delivery.

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