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Difficulty: EasyData Collection Techniques

A nurse is collecting postpartum data from a client who delivered a newborn 24 hours ago. When observing the client's lochia, which finding should the nurse identify as a potential complication that requires immediate reporting?

  1. A
    Dark red vaginal discharge that has a strong, fleshy odor
  2. B
    A brief gush of dark blood when the client first stands up from the bed
  3. A perineal pad that becomes completely saturated with blood within 15 minutesAnswer
  4. D
    The presence of several small blood clots that are the size of a dime

Answer

A perineal pad that becomes completely saturated with blood within 15 minutes
Saturating a perineal pad in 15 minutes or less is a definitive sign of excessive, rapid blood loss and indicates a potential postpartum hemorrhage. When collecting data on a postpartum client, this finding must be recognized immediately as a critical complication requiring escalation to the registered nurse or healthcare provider to stabilize the client.

Step-by-Step Solution

1
Analyze the timeframe of the client's delivery.
The client is 24 hours postpartum, which means lochia rubra (dark red bleeding) is expected.
Establishing the postpartum timeline determines which data collection findings are considered physiologically normal.
2
Evaluate each finding against normal postpartum expectations.
A fleshy odor, small clots, and a gush of blood upon standing are all normal variations of lochia rubra.
Differentiating between normal physiological changes and abnormal signs prevents unnecessary interventions and focuses attention on true risks.
3
Identify the finding that indicates excessive bleeding.
Saturating a pad in less than 15 minutes indicates severe, rapid blood loss.
This is a classic sign of postpartum hemorrhage that falls outside normal data collection parameters and requires immediate medical attention.

Key Concept

Data Collection of Normal vs. Abnormal Lochia
Estimated Time:1m 0s
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Topics

Data Collection Techniques

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