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Difficulty: EasyPhysiological Adaptation

A practical nurse (PN) is caring for a client who had a vaginal delivery two hours ago. The client's heart rate is 116 beats per minute, and blood pressure is 94/58 mm Hg. The client is restless and states, "I feel very lightheaded." Which action should the PN take first?

  1. Palpate the client's uterine fundus and evaluate the amount of vaginal bleedingAnswer
  2. B
    Document the vital signs as an expected physiological response to childbirth
  3. C
    Administer the prescribed as-needed oral analgesic for uterine cramping
  4. D
    Reassure the client that feeling lightheaded is a normal effect of maternal fatigue

Answer

The practical nurse should first palpate the client's uterine fundus and evaluate the amount of vaginal bleeding.
The client is exhibiting classic signs of early hypovolemic shock (tachycardia, hypotension, restlessness, lightheadedness). In the immediate postpartum period, the most common cause is uterine atony leading to hemorrhage. The practical nurse must immediately assess the fundus and vaginal bleeding to determine if hemorrhage is occurring, which addresses the 'Circulation' priority of the ABC framework.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has tachycardia (116 bpm), low blood pressure (94/58 mm Hg), restlessness, and lightheadedness two hours after birth.
Recognizing abnormal vital signs is the first step in identifying physiological instability.
2
Correlate the findings with potential postpartum complications.
These symptoms are classic early indicators of hypovolemic shock, likely due to postpartum hemorrhage.
Connecting data to potential risks guides the nurse toward the correct priority action.
3
Determine the priority nursing intervention using the ABC (Airway, Breathing, Circulation) framework.
Assessing the uterine fundus and lochia addresses Circulation by identifying the source of potential blood loss.
Immediate assessment of the circulatory status takes precedence over routine documentation, pain management, or providing reassurance.

Key Concept

Prioritization of Circulation in Postpartum Hemorrhage
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Topics

Physiological Adaptation

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