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Difficulty: MediumData Collection Techniques

A practical nurse (PN) is collecting data on a client who gave birth vaginally 4 hours ago. The PN observes that the client's perineal pad has become completely saturated with blood within 30 minutes of being changed. Which focused data collection action should the PN prioritize next?

  1. Palpate the uterine fundus to evaluate its firmness and position.Answer
  2. B
    Document the bleeding amount as expected lochia rubra for the early postpartum period.
  3. C
    Ask the client to rate their current level of perineal pain on a scale of 0 to 10.
  4. D
    Perform a comprehensive physical assessment to determine the physiological cause of the bleeding.

Answer

The correct action is to palpate the uterine fundus to evaluate its firmness and position.
The correct action involves palpating the uterine fundus to assess for uterine atony, which is the most common cause of early postpartum hemorrhage. This focused data collection technique safely falls within the practical nurse's scope of practice and provides immediate, critical information regarding the client's circulatory status that must be reported to the registered nurse for rapid intervention.

Step-by-Step Solution

1
Analyze the clinical finding.
The client is experiencing excessive vaginal bleeding, as saturating a perineal pad within 30 minutes is a classic indicator of postpartum hemorrhage.
Recognizing the difference between normal lochia and hemorrhage is critical for client safety.
2
Determine the priority framework.
Using the Airway, Breathing, and Circulation (ABC) framework, this is an active circulatory emergency that requires immediate investigation.
Severe bleeding compromises circulation and can rapidly lead to hypovolemic shock.
3
Select the appropriate focused data collection technique within the PN scope of practice.
The PN should palpate the uterine fundus to check for atony (a boggy uterus), which is the leading cause of early postpartum hemorrhage.
This focused physical assessment technique gathers essential data about uterine tone that must be immediately reported to the registered nurse.

Key Concept

Postpartum Focused Data Collection
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Topics

Data Collection Techniques

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