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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

While conducting a routine check on a client who is 8 hours postpartum following a vacuum-assisted vaginal birth of a 9-pound (4.08 kg) neonate, the practical nurse notes a firm, midline uterine fundus at the level of the umbilicus. The client has scant lochia rubra but reports severe, unrelenting vaginal pressure. The client's resting heart rate is 112 beats per minute. Which action should the practical nurse take first?

  1. Immediately alert the supervising registered nurse about the findingsAnswer
  2. B
    Administer the prescribed oral analgesic and apply a fresh ice pack to the perineal area
  3. C
    Perform a sterile inspection of the internal vaginal canal to locate the source of the pressure
  4. D
    Inform the client that the scant amount of lochia indicates the risk of postpartum hemorrhage has passed

Answer

Immediately alert the supervising registered nurse about the findings
The client's presentation of severe, unrelenting vaginal pressure, tachycardia, a firm fundus, and scant lochia is highly suspicious for a developing hematoma, a form of concealed postpartum hemorrhage. Because this represents a potential obstetric emergency that requires advanced assessment and potential surgical intervention, the practical nurse must immediately notify the registered nurse or healthcare provider. Timely escalation is critical to prevent severe hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's history and presenting data
The client had a vacuum-assisted birth of a large neonate and now presents with severe perineal pressure, tachycardia, a firm fundus, and scant lochia.
Identifying risk factors (instrument-assisted birth, macrosomia) and current symptoms helps differentiate between normal postpartum changes and complications.
2
Interpret the clinical significance of the findings
The combination of severe, unrelenting pressure, tachycardia, and a firm fundus with scant bleeding strongly suggests a developing hematoma (concealed hemorrhage), rather than uterine atony.
A firm fundus indicates the uterus is contracted, but tachycardia and severe pressure indicate ongoing hidden blood loss and tissue expansion.
3
Determine the appropriate nursing intervention based on scope of practice
The practical nurse must immediately notify the registered nurse or healthcare provider.
A hematoma is an obstetric emergency that requires advanced assessment and potential surgical intervention, which is beyond the practical nurse's scope to manage independently.

Key Concept

Postpartum Complications and Scope of Practice
Estimated Time:1m 30s
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Topics

Ante/Intra/Postpartum and Newborn Care

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