A practical nurse (PN) is collecting data on a client who is 4 hours postpartum following the vaginal delivery of a macrosomic neonate. The client reports feeling dizzy. The PN observes a continuous trickle of lochia rubra and a heart rate of 115 beats per minute. Which action should the practical nurse take first?
- AChange the perineal pad and document the amount of lochia as a heavy flow
- BIncrease the rate of the continuous intravenous oxytocin infusion
- Palpate the client's uterine fundus for firmness and positionAnswer
- DNotify the registered nurse immediately about the suspected hemorrhage
Answer
Palpate the client's uterine fundus for firmness and position
The client is exhibiting clinical signs of postpartum hemorrhage, including a continuous trickling of blood, tachycardia, and dizziness. Because the client delivered a macrosomic neonate, she is at high risk for uterine atony. The first and most critical independent action for the practical nurse is to palpate the fundus. This rapid assessment provides immediate data on whether the uterus is contracted. If the fundus is boggy, the practical nurse can immediately massage it to stimulate contraction, directly addressing the circulation component of the ABCs prior to reporting to the registered nurse.
Step-by-Step Solution
Key Concept
Postpartum Hemorrhage Assessment and Practical Nurse Scope of Practice