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Difficulty: HardData Collection Techniques

A client who gave birth vaginally 8 hours ago reports feeling faint and exhausted after standing up. The practical nurse (PN) observes that the client's skin is pale and clammy. The radial pulse is currently 114 beats per minute and the respiratory rate is 22 breaths per minute. Which focused data collection technique is the immediate priority for the PN to perform?

  1. A
    Monitor the saturation of the perineal pad over the next hour to quantify the volume of expected lochia.
  2. B
    Review the admission chart to determine if the current vital signs align with the client's prenatal baseline.
  3. Palpate the abdomen to determine the firmness and location of the uterine fundus.Answer
  4. D
    Auscultate the apical heart rate for one full minute to verify the presence of an arrhythmia.

Answer

Palpate the abdomen to determine the firmness and location of the uterine fundus.
The client is exhibiting early signs of hypovolemic shock (tachycardia, pallor, clammy skin, faintness), which in a postpartum client strongly indicates hemorrhage. Palpating the fundus is the immediate physical data collection technique required to determine if uterine atony is the source of the bleeding.

Step-by-Step Solution

1
Identify the clinical cues indicating a potential complication.
The client presents with pallor, clammy skin, faintness, and tachycardia (114 beats/min).
These assessment findings are classic early signs of hypovolemia or shock, which require urgent attention.
2
Determine the most likely cause of these signs in the current clinical context.
In a client who is 8 hours postpartum, the most common and immediate threat causing acute blood loss is uterine atony.
The uterus must remain firmly contracted to constrict blood vessels at the placental site and prevent hemorrhage.
3
Select the appropriate data collection technique to investigate this cause.
Palpating the uterine fundus directly evaluates its firmness and position.
Finding a boggy or displaced fundus immediately identifies the source of the bleeding, allowing the PN to intervene (e.g., fundal massage) and notify the RN/provider.

Key Concept

Postpartum Hemorrhage Recognition and Fundal Assessment
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Topics

Data Collection Techniques

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