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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

Following the vaginal delivery of a macrosomic infant 2 hours ago, a 25-year-old client reports feeling extremely thirsty and dizzy. The practical nurse (PN) observes that the uterine fundus is boggy and displaced to the right of the umbilicus. Additionally, the client's perineal pad has been completely saturated with lochia rubra within the last 30 minutes. Current vital signs reveal a heart rate of 112 beats/min and a blood pressure of 100/60 mm Hg. Which actions should the PN take? Select all that apply.

  1. Massage the uterine fundus firmly until it contracts.Answer
  2. Notify the registered nurse (RN) immediately about the clinical findings.Answer
  3. Weigh the saturated perineal pads to accurately quantify the client's blood loss.Answer
  4. D
    Reassure the client that saturating one pad in 30 minutes is expected at this stage.
  5. E
    Administer a prescribed intravenous (IV) push dose of oxytocin to control the bleeding.
  6. F
    Delegate the continuous monitoring of the client's vital signs to an unlicensed assistive personnel (UAP).

Answer

The appropriate actions are to massage the uterine fundus firmly, immediately notify the registered nurse, and weigh the saturated pads to quantify blood loss.
The client's presentation of a boggy, displaced fundus with rapid pad saturation, tachycardia, and dizziness are classic signs of postpartum hemorrhage and early hypovolemic shock (compounded by a full bladder). The immediate priority is to physically stimulate the uterus to contract by massaging the fundus. Because the client is hemodynamically unstable, the PN is required to immediately notify the RN to facilitate advanced interventions. Weighing the saturated pads is an appropriate independent data collection action within the PN's scope to precisely quantify blood loss for the healthcare provider.

Step-by-Step Solution

1
Analyze the client's clinical findings and symptom presentation.
The combination of a boggy fundus, saturated pad in 30 minutes, dizziness, thirst, and tachycardia indicates active postpartum hemorrhage and early hypovolemic shock.
Recognizing life-threatening complications is the first step in prioritizing clinical interventions.
2
Determine the immediate priority physical intervention.
The nurse must immediately massage the boggy fundus.
Fundal massage mechanically stimulates the uterine muscle fibers to contract, which is the most direct way to tamponade bleeding vessels at the placental site.
3
Evaluate the planned actions against the PN scope of practice.
The PN must report the unstable findings to the RN and collect data by weighing pads, while avoiding out-of-scope actions like IV push medications or improper delegation.
Maintaining client safety requires strict adherence to legal and professional boundaries regarding task delegation and medication administration.

Key Concept

Recognition of postpartum hemorrhage and adherence to PN scope of practice during obstetric emergencies.
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Topics

Ante/Intra/Postpartum and Newborn Care

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