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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A practical nurse is assigned to the maternal-newborn unit and is evaluating a client who is 8 hours postpartum following a spontaneous vaginal birth. The client states that she has completely saturated three perineal pads within the last hour. During data collection, the practical nurse notes a maternal heart rate of 114 beats per minute and a blood pressure of 102/64 mm Hg. Which of the following actions is the priority for the practical nurse?

  1. Promptly report the findings to the supervising registered nurse for immediate intervention.Answer
  2. B
    Reassure the client that a heavy flow of lochia rubra is a normal expectation during the first day postpartum.
  3. C
    Document the amount of vaginal bleeding and continue to monitor the client's vital signs every four hours.
  4. D
    Instruct the unlicensed assistive personnel to perform frequent fundal massages on the client.

Answer

The priority action is to promptly report the findings to the supervising registered nurse for immediate intervention.
Saturating a perineal pad in 15 to 30 minutes, or multiple pads within an hour, combined with an elevated resting heart rate (tachycardia) is a classic presentation of postpartum hemorrhage. The practical nurse must prioritize notifying the registered nurse or provider immediately so that advanced interventions can be initiated to prevent severe hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's reported lochia volume and vital signs.
The client saturated three pads in one hour and has a heart rate of 114 beats per minute.
Recognizing the early clinical indicators of postpartum hemorrhage (excessive bleeding rate and tachycardia) is critical for prioritizing care.
2
Determine the appropriate response based on the practical nurse's scope of practice.
The situation requires immediate escalation to the registered nurse.
An unstable client displaying signs of hemorrhage and early hypovolemic shock requires RN-level assessment and rapid provider intervention.

Key Concept

Identifying and escalating signs of postpartum hemorrhage
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Topics

Ante/Intra/Postpartum and Newborn Care

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