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Difficulty: Very hardAnte/Intra/Postpartum and Newborn Care

During morning rounds on the maternity unit, the practical nurse (PN) evaluates a primigravida client who had a vaginal delivery 12 hours ago with an epidural. The client's current vital signs are blood pressure 104/64 mm Hg, heart rate 112 beats/minute, and respiratory rate 20 breaths/minute. The client states, 'I feel incredibly thirsty and a little dizzy when I sit up.' The fundus is firm, midline, and located at the umbilicus. A continuous trickle of bright red vaginal bleeding is noted. Which of the following actions should the PN take? (Select all that apply.)

  1. Notify the registered nurse (RN) immediately regarding the continuous bleeding and current vital signsAnswer
  2. Weigh the client's blood-soaked perineal pads to accurately quantify the volume of blood lossAnswer
  3. Inspect the client's perineal area visually to gather data on the presence of hematomas or unrepaired lacerationsAnswer
  4. D
    Vigorously massage the client's fundus for several minutes to encourage expulsion of retained blood clots
  5. E
    Administer a prescribed intravenous (IV) bolus of oxytocin to ensure sustained uterine contraction
  6. F
    Document the vital signs and client's report of dizziness as expected fluid shifts of the postpartum period

Answer

The practical nurse should immediately notify the registered nurse, weigh the perineal pads to quantify blood loss, and visually inspect the perineum to gather data regarding potential lacerations.
A continuous trickle of bright red blood in the presence of a firm, midline fundus is a cardinal sign of a birth canal laceration, not uterine atony. The client's tachycardia (112 beats/minute), thirst, and dizziness are early compensatory indicators of hypovolemic shock. The PN must prioritize client safety by immediately notifying the RN for advanced assessment, gathering objective data by weighing pads for quantitative blood loss, and inspecting the perineum to help identify the source of bleeding.

Step-by-Step Solution

1
Analyze the vital signs and client statements.
The client has tachycardia (112 beats/minute), dizziness, and thirst.
These findings point toward early compensatory hypovolemic shock, despite the blood pressure appearing relatively normal.
2
Evaluate the source of the bleeding based on physical findings.
The fundus is firm and midline, but there is a continuous trickle of bright red blood.
A firm fundus rules out uterine atony; continuous bleeding in the presence of a contracted uterus strongly suggests a cervical or vaginal laceration.
3
Determine appropriate interventions within the PN scope of practice.
Appropriate actions include notifying the RN, inspecting the perineum visually, and weighing the pads.
The PN must gather accurate objective data (visual inspection, quantitative blood loss) while escalating the critical findings to the RN for advanced assessment and collaborative management.
4
Rule out contraindicated or out-of-scope interventions.
Avoid fundal massage, avoid dismissing the vital signs, and avoid IV bolus medications.
Massaging a firm fundus is incorrect for lacerations, documenting shock signs as normal is dangerous, and IV bolus of oxytocin is out of scope and clinically unindicated here.

Key Concept

Differentiating between uterine atony and birth canal lacerations as causes of postpartum hemorrhage, recognizing early signs of hypovolemic shock, and acting safely within the PN scope of practice.
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Topics

Ante/Intra/Postpartum and Newborn Care

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