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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

An LPN/VN is assigned to the care of a client who experienced a forceps-assisted vaginal birth 24 hours ago. The client suddenly reports excruciating, unrelenting perineal pain and significant rectal pressure that was not relieved by an oral analgesic. Data collection reveals a firm, midline uterine fundus located at the umbilicus and a scant amount of lochia rubra on the perineal pad. Which action should the practical nurse take first?

  1. Assist the client to a side-lying position and visually examine the perineal and rectal area.Answer
  2. B
    Begin vigorous massage of the lower abdomen to promote uterine contraction.
  3. C
    Contact the registered nurse immediately to request a prescription for a stronger pain medication.
  4. D
    Help the client to the bathroom to ensure the bladder is completely empty.

Answer

The practical nurse should first assist the client to a side-lying position and visually examine the perineal area to collect data regarding a potential hematoma.
The client's presentation of unrelenting perineal pain and rectal pressure following an operative vaginal delivery (forceps) is the classic hallmark of a perineal hematoma. Because the fundus is firm and midline with minimal visible bleeding, uterine atony is ruled out. The practical nurse's priority is to utilize their data collection skills to visually inspect the perineum for swelling, tension, and bluish discoloration before immediately reporting the findings to the registered nurse.

Step-by-Step Solution

1
Evaluate the client's subjective symptoms against the objective data.
The client reports severe pain and rectal pressure, but objective data shows a firm, midline fundus and scant lochia.
This differentiation rules out uterine atony and points toward a concealed hemorrhage, such as a perineal or vaginal hematoma, which is common after a forceps-assisted delivery.
2
Determine the most appropriate immediate action within the practical nursing scope of practice.
The nurse must visually inspect the perineum to confirm swelling, bluish discoloration, or extreme tenderness.
Direct data collection is a necessary independent nursing action before escalating the clinical findings to the registered nurse or healthcare provider.

Key Concept

Identifying complications of the postpartum period and prioritizing data collection within the PN scope of practice.
Estimated Time:1m 15s
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Topics

Ante/Intra/Postpartum and Newborn Care

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