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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

While providing care on a busy maternal-newborn unit, the practical nurse (PN) evaluates several clinical situations. Which action demonstrates appropriate clinical judgment and adherence to the PN scope of practice?

  1. A
    Accepting a task delegation to administer an intravenous (IV) push opioid analgesic for a client experiencing severe postoperative pain following a cesarean birth.
  2. B
    Applying continuous, vigorous fundal massage for a client whose uterus is firm and midline because the client passed a dark red gush of lochia upon standing.
  3. Alerting the registered nurse (RN) to evaluate a 5-hour postpartum client who reports feeling lightheaded and has a resting heart rate of 114 bpm.Answer
  4. D
    Documenting a positive Babinski reflex in a 16-hour-old term neonate as an acute neurological deficit requiring immediate provider notification.

Answer

Alerting the registered nurse (RN) to evaluate a 5-hour postpartum client who reports feeling lightheaded and has a resting heart rate of 114 bpm.
The correct action is recognizing the early signs of potential hypovolemic shock (unexplained tachycardia and lightheadedness) in a postpartum client and appropriately escalating the situation to the RN for advanced assessment. The PN is responsible for careful data collection and reporting subtle deviations from baseline that could precede a major complication like postpartum hemorrhage.

Step-by-Step Solution

1
Evaluate each option against the established standards of maternal-newborn physiology and the legal scope of practice for a PN.
Identify three actions that represent clinical errors or scope violations and one action that represents correct prioritization.
Safe nursing practice requires distinguishing between normal findings, out-of-scope tasks, and subtle signs of clinical deterioration.
2
Analyze the action regarding IV push medications.
Recognize that IV push administration is outside the PN scope of practice, making this an inappropriate action.
The PN must not accept delegations that require RN-level pharmacology privileges.
3
Analyze the action regarding the dark red gush of lochia.
Recognize that vaginal pooling of lochia when supine often causes a transient gush upon standing. If the fundus is firm, massage is unnecessary and potentially harmful.
Massaging a firm fundus can lead to uterine muscle fatigue and subsequent atony.
4
Analyze the action regarding the neonate's Babinski reflex.
Identify that a positive Babinski reflex is a normal developmental milestone for a 16-hour-old neonate.
Mistaking normal newborn reflexes for neurological deficits leads to unnecessary interventions.
5
Analyze the action regarding the lightheaded, tachycardic postpartum client.
Identify tachycardia (114 bpm) and lightheadedness as early indicators of hypovolemia or hemorrhage. Escalating this to the RN is the correct, high-priority action.
The PN plays a vital role in early data collection and recognizing trends that precede severe postpartum complications.

Key Concept

Prioritization, early complication recognition, and adherence to the PN scope of practice in maternal-newborn care.
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Topics

Ante/Intra/Postpartum and Newborn Care

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