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Difficulty: Very hardAnte/Intra/Postpartum and Newborn Care

An assessment is being performed by the practical nurse on a multiparous client who delivered a macrosomic neonate precipitously three hours ago. The client states, "I feel very thirsty and I just cannot get comfortable." The current vital signs reveal a heart rate of 118 beats/min, respirations of 24 breaths/min, and blood pressure of 102/68 mmHg. Palpation of the abdomen reveals a firm, midline uterine fundus at the level of the umbilicus. Inspection of the perineum shows a steady, continuous trickle of bright red blood. What is the priority nursing action?

  1. Report the clinical findings to the supervising registered nurse immediately.Answer
  2. B
    Perform a vigorous, continuous massage of the uterine fundus.
  3. C
    Direct an unlicensed assistive personnel to provide large amounts of oral fluids.
  4. D
    Record the expected postpartum findings and plan to recheck vitals in one hour.

Answer

Report the clinical findings to the supervising registered nurse immediately.
The correct answer addresses the urgent need for medical evaluation based on signs of hypovolemic shock and bleeding from a suspected laceration. Because the fundus is already firm, nursing interventions for atony (like massage) are not indicated. The practical nurse must recognize the critical nature of a steady trickle of blood combined with tachycardia and thirst, and immediately escalate the situation to the registered nurse or healthcare provider to prevent severe hemodynamic collapse.

Step-by-Step Solution

1
Analyze the client's vital signs and subjective symptoms.
The client has tachycardia (118 beats/min), tachypnea (24 breaths/min), thirst, and restlessness, which are early compensatory signs of hypovolemic shock.
Recognizing early physiological deterioration is essential for timely intervention before severe hypotension occurs.
2
Evaluate the uterine fundus and lochia characteristics.
The fundus is firm and midline, but there is a continuous trickle of bright red blood.
A firm fundus rules out uterine atony as the source of bleeding. A continuous trickle of blood with a firm fundus points directly to trauma, such as a vaginal or cervical laceration from the precipitous birth of a macrosomic infant.
3
Determine the practical nurse's scope of practice.
Diagnosing a laceration and ordering advanced interventions (like surgical repair or massive blood transfusion) are outside the PN scope.
The PN must recognize the critical deviation from normal and immediately escalate the findings to the RN or healthcare provider.

Key Concept

Postpartum Hemorrhage Assessment and Scope of Practice
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Topics

Ante/Intra/Postpartum and Newborn Care

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