Postpartum Assessment (BUBBLE-HE) on the NCLEX
The BUBBLE-HE postpartum assessment: fundal checks, what is normal, and the findings that mean hemorrhage or infection.
BUBBLE-HE organizes the postpartum assessment, and NCLEX pulls its questions straight from the abnormal column.
B: Breasts
Soft days 1-2, filling by day 3. Check nipples for cracks or blisters (usually a latch problem). Engorgement: warm compresses and feeding if breastfeeding; cold compresses and a supportive bra if not. A firm, red, painful area with fever later on suggests mastitis.
U: Uterus
Firm, midline, at the umbilicus after delivery, descending about one fingerbreadth (1 cm) per day. Boggy fundus → massage first, then reassess. Fundus deviated to the right → full bladder. Have her void, then recheck. A displaced bladder prevents uterine contraction and invites hemorrhage.
B: Bladder and B: Bowel
Voiding within 6-8 hours of delivery. Measure the first voids; retention with overflow dribbling is common after epidurals. Bowel: encourage fluids, fiber, ambulation. Stool softeners are routine after repairs; avoid straining.
L: Lochia and E: Episiotomy/perineum
Lochia progresses rubra → serosa → alba and should never smell foul. Saturating a pad in an hour or less, or passing large clots, is hemorrhage until proven otherwise. Perineum: assess with REEDA (redness, edema, ecchymosis, discharge, approximation). Ice packs the first 24 hours, then sitz baths.
H: Extremities, E: Emotions
Legs: assess for unilateral calf swelling, redness, or pain (DVT risk is elevated postpartum). Encourage early ambulation. Emotions: baby blues (tearfulness, mood swings) peak in the first two weeks and self-resolve. Symptoms past two weeks, inability to care for self or baby, or any thought of harm → screen for postpartum depression and refer.
Frequently asked
Fundus is boggy. Massage or call the provider first?
Massage first. It is the immediate independent intervention. Reassess, then escalate if the uterus will not stay firm or bleeding continues.
How fast should the fundus descend?
About one fingerbreadth per day. By day 10 it should no longer be palpable abdominally. A uterus that stays high or stops descending suggests subinvolution or a full bladder.
When are postpartum vitals and fundal checks most frequent?
The first hour after delivery, typically every 15 minutes per protocol. That is the peak hemorrhage window.
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