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Question

Difficulty: EasyEstablishing Priorities

While rounding on a postpartum unit, a nurse is notified of several client needs. Which client condition requires the nurse's immediate clinical evaluation?

  1. A
    A client who delivered vaginally 2 hours ago and complains of moderate uterine cramping while breastfeeding
  2. B
    A client who had a cesarean birth 12 hours ago and reports incisional pain rated 6 on a 0 to 10 scale
  3. A client who delivered vaginally 3 hours ago and has a resting heart rate of 118 bpm with a perineal pad that saturated in 20 minutesAnswer
  4. D
    A client who delivered vaginally 24 hours ago and is crying because the newborn has difficulty latching

Answer

The client who delivered 3 hours ago with a resting heart rate of 118 bpm and a rapidly saturating perineal pad requires immediate clinical evaluation.
This client is experiencing signs of postpartum hemorrhage, which is a life-threatening circulatory emergency. A resting heart rate of 118 bpm (tachycardia) is an early physiological indicator of hypovolemic shock, and saturating a perineal pad in less than an hour requires immediate intervention to stabilize the client's circulation. According to the ABC (Airway, Breathing, Circulation) framework, this physiological instability is the absolute highest priority.

Step-by-Step Solution

1
Analyze each client's condition to identify expected versus unexpected findings.
The crying client, the client with incisional pain, and the client with uterine cramping all exhibit expected postpartum findings. The client with a rapid heart rate and heavy bleeding exhibits unexpected, acute findings.
Recognizing normal physiological adaptation helps isolate clients experiencing acute complications.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client with tachycardia (118 bpm) and rapid pad saturation is showing signs of compromised circulation due to severe bleeding.
The ABC framework dictates that circulatory compromise is a life-threatening emergency that must take precedence over pain, routine physiological changes, and psychosocial needs.

Key Concept

Prioritizing acute circulatory compromise over expected postpartum findings using the ABC framework.
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Topics

Establishing Priorities

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