A practical nurse is collecting data on a client who is 4 hours postpartum following a spontaneous vaginal delivery. The client's uterine fundus is firm, midline, and located at the umbilicus. The client has saturated one perineal pad over the past 3 hours. The client reports feeling increasingly lightheaded and excessively thirsty. Current vital signs reveal a heart rate of 118 bpm, respirations of 22 breaths/min, and a blood pressure of 102/64 mm Hg. Which action should the practical nurse take first?
- Inspect the client's perineal area for the presence of a hematoma.Answer
- BOffer the client oral fluids to alleviate the reported thirst.
- CDocument the findings as expected normal postpartum adaptations.
- DPerform vigorous fundal massage to expel any retained placental fragments.
Answer
The practical nurse should first inspect the client's perineal area for the presence of a hematoma.
The correct action is to inspect the perineal area. The client's tachycardia, lightheadedness, and severe thirst are compensatory mechanisms for volume depletion (hypovolemia). Because the uterine fundus is firm and external bleeding is minimal, the nurse must suspect a concealed hemorrhage, such as a perineal or vaginal hematoma. Visual inspection of the perineum is the most direct way to gather this critical data before notifying the registered nurse.
Step-by-Step Solution
Key Concept
Recognizing concealed postpartum hemorrhage and early signs of hypovolemic shock.