A practical nurse (PN) is gathering data from a client who is 36 hours postpartum following an uncomplicated vaginal delivery of a term neonate at 40 weeks gestation. The client reports feeling very fatigued and mentions soaking a perineal pad from front to back every 45 minutes for the past two hours. The client's vital signs are temperature 99.0°F (37.2°C), heart rate 112 beats/minute, respirations 20 breaths/minute, and blood pressure 104/64 mm Hg. Which of the following actions should the PN take? Select all that apply.
- Palpate the client's abdomen to evaluate the firmness and location of the uterine fundus.Answer
- BDocument the amount of lochia as an expected, normal finding for 36 hours postpartum.
- Inquire if the client has emptied her bladder within the last two hours.Answer
- DReassure the client that a heart rate of 112 beats/minute is a typical physiological adaptation after birth.
- EIndependently initiate an intravenous (IV) push uterotonic medication to manage the excessive bleeding.
- Notify the registered nurse (RN) immediately regarding the client's vital signs and bleeding.Answer
Answer
The PN should palpate the abdomen to evaluate the fundus, inquire about the client's last void, and notify the registered nurse immediately.
The client's presentation of soaking a perineal pad in less than an hour coupled with tachycardia (heart rate of 112 beats/minute) strongly suggests postpartum hemorrhage and early compensatory shock. The appropriate response for a practical nurse is to gather focused, pertinent data to identify the cause (evaluating the fundus for atony and checking if a full bladder is displacing the uterus) while concurrently escalating the critical situation to the registered nurse for advanced assessment and collaborative management.
Step-by-Step Solution
Key Concept
Postpartum Hemorrhage Recognition and PN Scope of Practice