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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A practical nurse is caring for a client who gave birth vaginally 4 hours ago. While conducting a routine check, which of the following observations or events should the nurse identify as requiring immediate escalation to the registered nurse? Select all that apply.

  1. The client requires a new sanitary pad after completely soaking the current one in 30 minutes.Answer
  2. The client's pulse reading elevates to 112 beats per minute while resting quietly in bed.Answer
  3. The client reports severe, escalating vaginal pressure that is unaffected by prescribed oral pain medications.Answer
  4. D
    The client experiences a transient release of dark red vaginal drainage when shifting from a supine to a standing position.
  5. E
    The client's uterine fundus feels contracted and is situated along the midline at the level of the navel.
  6. F
    The client states a desire to exclusively breastfeed and requests assistance with basic infant positioning.

Answer

The observations requiring immediate escalation include completely soaking a sanitary pad in 30 minutes, an elevated resting pulse of 112 beats per minute, and severe, escalating vaginal pressure unrelieved by pain medication.
Postpartum hemorrhage and hematoma formation are life-threatening complications that require immediate medical intervention beyond the practical nurse (PN) scope of practice. Saturated sanitary pads in under an hour indicate excessive bleeding. A rising resting heart rate is often the earliest subtle sign of compensatory shock due to blood loss. Severe, unrelieved vaginal pressure strongly suggests an expanding pelvic or vaginal hematoma. All three situations require prompt escalation to the registered nurse (RN) or healthcare provider.

Step-by-Step Solution

1
Evaluate each finding to determine if it represents an expected postpartum physiological change or a potential complication.
Soaking a pad in 30 minutes, resting tachycardia (112 bpm), and severe unrelieved pressure are abnormal. Pooling of lochia upon standing, a firm midline fundus, and requests for basic breastfeeding assistance are expected or routine.
Differentiating between normal involution processes and life-threatening emergencies is critical for prioritizing care safely.
2
Determine which of the abnormal findings fall outside the independent scope of the practical nurse and require escalation.
Hemorrhage, early shock, and suspected hematomas require advanced RN assessment and provider intervention.
The PN must recognize subtle signs of instability and escalate promptly to ensure client safety.

Key Concept

Identifying postpartum hemorrhage and hematoma signs requiring immediate RN escalation
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Topics

Ante/Intra/Postpartum and Newborn Care

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