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Difficulty: EasyData Collection Techniques

While providing care for a client who had a vaginal delivery 24 hours ago, a practical nurse observes that the client's perineal pad is entirely saturated with bright red blood after being in place for only 30 minutes. Which immediate data collection technique should the nurse prioritize?

  1. A
    Conduct a comprehensive internal pelvic examination to identify the exact origin of the active bleeding.
  2. B
    Record the observation in the chart as an expected normal finding for the first 24 hours postpartum.
  3. Palpate the client's abdomen to assess the firmness and location of the uterine fundus.Answer
  4. D
    Delay further physical checks and continue with routine care since the client is otherwise resting comfortably.

Answer

Palpate the client's abdomen to assess the firmness and location of the uterine fundus.
Palpating the uterine fundus is a targeted, non-invasive data collection technique that immediately helps determine if the uterus is boggy (atonic), which is the most common cause of postpartum hemorrhage. This action falls safely within the practical nurse's scope and directs the next critical interventions.

Step-by-Step Solution

1
Identify the clinical significance of a perineal pad saturated within 30 minutes.
Recognize this presentation as an early sign of potential postpartum hemorrhage.
Early identification of excessive blood loss is critical to prevent life-threatening hypovolemic shock.
2
Determine the appropriate focused data collection technique within the practical nursing scope of practice.
Select external fundal palpation.
Palpating the fundus helps determine if uterine atony is the cause of the excessive bleeding, which safely guides immediate nursing interventions like fundal massage.

Key Concept

Focused Data Collection for Postpartum Hemorrhage
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Topics

Data Collection Techniques

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