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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A practical nurse is caring for a client who is 4 hours postpartum following a prolonged vaginal delivery. The client's baseline vital signs upon admission to the postpartum unit were blood pressure 118/76 mm Hg and heart rate 82 beats/min. The current vital signs are blood pressure 92/58 mm Hg and heart rate 118 beats/min. The client's fundus is firm, midline, and at the umbilicus, with moderate lochia rubra. Which action should the practical nurse take?

  1. A
    Administer a prescribed intravenous fluid bolus to increase the blood pressure
  2. B
    Document the vital signs as a normal physiological response to fluid loss during birth
  3. Notify the registered nurse immediately regarding the vital sign changesAnswer
  4. D
    Perform vigorous fundal massage to expel any potential retained placental fragments

Answer

Notify the registered nurse immediately regarding the vital sign changes
The correct answer involves notifying the registered nurse immediately. The client's significant tachycardia (118 beats/min) and hypotension (92/58 mm Hg) are early, critical signs of hypovolemic shock. Because the fundus is firm and lochia is moderate, this bleeding may be concealed (such as a vaginal or pelvic hematoma) or from a cervical laceration. The practical nurse must recognize these abnormal vital signs and promptly escalate the situation to the registered nurse for comprehensive assessment and rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's vital sign trends by comparing baseline to current readings.
The blood pressure has decreased significantly (hypotension) and the heart rate has increased significantly (tachycardia).
Identifying significant deviations from baseline vital signs helps detect potential physiological instability and complications.
2
Evaluate the current postpartum physical assessment findings in relation to the vital signs.
The fundus is firm and midline with moderate lochia, indicating that uterine atony is not the likely cause of the vital sign changes.
Ruling out a boggy uterus helps determine that the instability might be caused by an unobserved issue, such as a cervical laceration or internal hematoma.
3
Determine the safest and most appropriate intervention based on the practical nurse's scope of practice.
The practical nurse must alert the registered nurse immediately about the client's deteriorating status.
Practical nurses must recognize early signs of shock and escalate care, as independent management of unstable clients is outside their designated scope.

Key Concept

Recognizing early signs of postpartum hypovolemic shock and adhering to practical nurse scope of practice
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Topics

Ante/Intra/Postpartum and Newborn Care

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