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Difficulty: HardPhysiological Adaptation

The practical nurse (PN) is collecting data on a client who is 4 hours postpartum following a vaginal delivery of a large-for-gestational-age newborn. Which assessment findings indicate a complication of physiological adaptation requiring immediate notification of the registered nurse (RN)? Select all that apply.

  1. A perineal pad completely saturated with blood within 20 minutes.Answer
  2. Resting heart rate increasing from 76 to 114 beats per minute.Answer
  3. Client report of severe, unremitting perineal pressure.Answer
  4. D
    Intermittent, dull uterine cramping while breastfeeding.
  5. E
    An oral temperature of 100.1∘F100.1^\circ\text{F} (37.8∘C37.8^\circ\text{C}).
  6. F
    A white blood cell (WBC) count of 18,000/mm318,000 / \text{mm}^3.

Answer

The correct findings requiring immediate notification are rapid pad saturation, a progressively increasing resting heart rate, and severe, unremitting perineal pressure.
The correct selections represent acute, life-threatening complications of postpartum adaptation. A rapidly saturated pad indicates overt hemorrhage. Tachycardia is a subtle, early compensatory mechanism for hypovolemia. Unremitting perineal pressure strongly suggests a concealed hemorrhage (hematoma). All three require emergency intervention to prevent severe hemodynamic instability.

Step-by-Step Solution

1
Analyze the client's current status and risk factors.
The client is 4 hours postpartum after delivering a large-for-gestational-age infant, placing her at high risk for uterine atony, hemorrhage, and perineal trauma.
Identifying specific clinical risks guides the PN to anticipate potential life-threatening complications.
2
Evaluate each finding to differentiate between expected physiological adaptation and acute decompensation.
Heavy bleeding, tachycardia, and severe localized pressure indicate active or concealed blood loss. Uterine cramping during feeding, slight temperature elevation, and elevated WBCs are expected normal variants in the immediate postpartum period.
The PN must accurately interpret clinical data to avoid missing early signs of shock or escalating normal findings unnecessarily.
3
Determine the priority nursing action based on the identified data.
The abnormal findings threaten Airway, Breathing, and Circulation (ABCs) via hypovolemic shock and require immediate escalation to the RN for medical intervention.
Prompt recognition and reporting of clinical deterioration fall squarely within the PN scope of practice for maintaining physiological integrity.

Key Concept

Early recognition of postpartum hemorrhage and hematoma versus expected normal physiological adaptations (afterpains, transient hyperthermia, and leukocytosis).
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Topics

Physiological Adaptation

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