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Difficulty: HardReduction of Risk Potential

A practical nurse (PN) is monitoring a client who had an uncomplicated vaginal delivery 3 hours ago. The client is resting in bed and states, "I feel suddenly very weak and a bit dizzy when I lift my head." The PN notes that the client has saturated one perineal pad over the last 45 minutes. The client's skin is cool and slightly clammy. Vital signs reveal a heart rate of 112 beats/min and a blood pressure of 98/60 mm Hg. Which of the following is the priority action for the PN?

  1. Palpate the uterine fundus and immediately begin fundal massage if it feels soft or boggy.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position to help alleviate the client's dizziness.
  3. C
    Reassure the client that these symptoms are expected and reassess the vital signs in 30 minutes.
  4. D
    Document the saturated pad as a normal clearance of lochia rubra during the early postpartum period.

Answer

The priority action is to palpate the uterine fundus and immediately begin fundal massage if it feels soft or boggy.
The client's presentation of saturating a perineal pad in under an hour, combined with tachycardia, hypotension, dizziness, and clammy skin, points directly to postpartum hemorrhage and early hypovolemic shock. The most common cause of early postpartum hemorrhage is uterine atony (failure of the uterus to contract). The priority and most effective initial action for the practical nurse is to assess the uterine fundus. If it is soft or boggy, immediate fundal massage must be initiated to stimulate contraction and compress the bleeding vessels before further assistance is summoned.

Step-by-Step Solution

1
Analyze the clinical findings.
The client has saturated a pad in 45 minutes, has tachycardia (112 bpm), hypotension (98/60 mm Hg), clammy skin, and dizziness.
Recognizing the combination of excessive bleeding and abnormal vital signs identifies the complication as postpartum hemorrhage leading to hypovolemic shock.
2
Determine the priority nursing intervention.
The most common cause of early postpartum hemorrhage is uterine atony. The first action must address the immediate source of bleeding.
By prioritizing airway, breathing, and circulation (ABC), stopping the bleeding is the immediate necessity.
3
Select the correct PN action.
Palpating the fundus and massaging it if boggy is the appropriate direct intervention within the PN's scope of practice.
Fundal massage stimulates uterine contraction, which compresses bleeding vessels and reduces hemorrhage.

Key Concept

Postpartum Hemorrhage and Hypovolemic Shock Recognition
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Topics

Reduction of Risk Potential

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