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Difficulty: Very hardAnte/Intra/Postpartum and Newborn Care

A 30-year-old client is 6 hours postpartum following a vaginal delivery of twins. The client is receiving a continuous intravenous infusion of Lactated Ringer's. Over the past 4 hours, the practical nurse (PN) notes the client's blood pressure has decreased from 122/80 mm Hg to 104/68 mm Hg, and the heart rate has increased from 82 to 108 beats/minute. The fundus is firm, midline, and 1 cm below the umbilicus. Scant lochia rubra is observed on the perineal pad. The client reports new, severe, unrelenting rectal pain and deep pelvic pressure that is not relieved by the prescribed oral ibuprofen. Which action is the priority for the PN to take?

  1. Notify the registered nurse immediately about the client's vital sign trends and the report of severe rectal painAnswer
  2. B
    Document the vital signs and administer the prescribed oral opioid analgesic for the pain
  3. C
    Perform firm, continuous fundal massage to express any blood clots that may be causing the pressure
  4. D
    Assist the client in using a bedpan to rule out a distended bladder as the cause of the pelvic pressure

Answer

The correct action is to notify the registered nurse immediately about the client's vital sign trends and the report of severe rectal pain.
The client is exhibiting classic signs of a concealed postpartum hemorrhage, specifically a vaginal or vulvar hematoma. The dropping blood pressure and rising heart rate are early signs of hypovolemic shock. Because the fundus is firm and midline with only scant lochia, the bleeding is not from uterine atony. Severe, unrelenting rectal pain and deep pelvic pressure occur as the hematoma expands and compresses surrounding tissues. The practical nurse must prioritize communicating these critical, life-threatening changes to the registered nurse immediately for collaborative intervention.

Step-by-Step Solution

1
Analyze the client's vital sign trends.
Blood pressure is decreasing and heart rate is increasing.
These are early physiological indicators of hypovolemia and compensatory shock.
2
Evaluate the uterine assessment findings.
The fundus is firm and midline with minimal external bleeding.
This rules out uterine atony as the cause of the vital sign changes, suggesting a concealed source of blood loss.
3
Correlate the subjective pain characteristics with the objective data.
The severe, unrelenting rectal pain combined with shock indicators points to an expanding pelvic hematoma.
Hematomas cause extreme pressure on the rectum and surrounding tissues while sequestering large amounts of blood.
4
Determine the priority nursing action within the PN scope of practice.
The priority is to immediately notify the RN.
A suspected hematoma with hypovolemic shock is a medical emergency requiring RN assessment, provider notification, and potential surgical intervention.

Key Concept

Recognizing Signs of Concealed Postpartum Hemorrhage (Hematoma) and Shock
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Topics

Ante/Intra/Postpartum and Newborn Care

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