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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

A nurse receives handoff report for a client who is 4 hours postpartum following a forceps-assisted vaginal delivery of an 8 lb 12 oz (3.97 kg) neonate. The client reports intense, deep pelvic pain and severe rectal pressure. The previous shift's assessment noted a firm, midline fundus, scant lochia rubra, heart rate of 118 bpm, and blood pressure of 92/58 mm Hg. Which action is the highest priority for the nurse to take?

  1. A
    Administer the prescribed as-needed intravenous opioid analgesic for severe pain
  2. Inspect the client's perineal and vulvar area for localized swelling and discolorationAnswer
  3. C
    Delegate the unlicensed assistive personnel to re-evaluate the vital signs in 15 minutes
  4. D
    Massage the client's fundus vigorously and attempt to express any retained blood clots

Answer

Inspect the client's perineal and vulvar area for localized swelling and discoloration
The client's presentation of severe pelvic pain, extreme rectal pressure, a firm fundus, scant lochia, tachycardia, and borderline hypotension is highly suspicious for a vulvar, vaginal, or retroperitoneal hematoma. A hematoma is a localized collection of blood in the tissues resulting from vessel damage, often associated with operative deliveries (forceps) and macrosomia. It can cause massive concealed hemorrhage, leading to hypovolemic shock despite minimal external bleeding. The nurse's highest priority is to inspect the perineum to confirm the presence of a hematoma so that prompt medical or surgical intervention can be initiated.

Step-by-Step Solution

1
Analyze the client's risk factors and presenting symptoms.
The client had a forceps-assisted delivery of a macrosomic infant, placing her at high risk for tissue trauma. She now has severe pelvic pain and rectal pressure.
Identifying risk factors helps narrow down the potential postpartum complications.
2
Evaluate the objective clinical findings (vital signs and physical assessment).
The fundus is firm with scant lochia, ruling out uterine atony. However, the client is tachycardic (118 bpm) and hypotensive (92/58 mm Hg).
Vital sign trends are critical for detecting early signs of shock that are disproportionate to the visible blood loss.
3
Synthesize the data to determine the likely complication and prioritize nursing action.
Intense pain, rectal pressure, and signs of shock with a firm fundus indicate a concealed hemorrhage, such as a vaginal or vulvar hematoma. The nurse must inspect the area to confirm.
The nursing process dictates that focused assessment must precede interventions when a new complication is suspected.

Key Concept

Recognition and assessment of postpartum hematoma and concealed hemorrhage
Estimated Time:1m 30s
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Topics

Ante/Intra/Postpartum and Newborn Care

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