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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is caring for a client who is 2 hours postpartum following a precipitous vaginal delivery. The client reports feeling lightheaded, and the nurse observes that a fresh perineal pad has become entirely saturated with blood within 15 minutes. Which of the following actions should the nurse take? Select all that apply.

  1. Firmly massage the uterine fundus to stimulate contraction and minimize bleeding.Answer
  2. B
    Wait for a significant decrease in systolic blood pressure before notifying the healthcare provider.
  3. Assess the client for a narrowing pulse pressure and mild tachycardia.Answer
  4. D
    Delegate the initiation of supplemental oxygen therapy to the unlicensed assistive personnel (UAP).
  5. Prepare to establish an additional large-bore intravenous (IV) line.Answer
  6. F
    Assist the client in ambulating to the bathroom to independently empty their bladder.

Answer

The nurse should firmly massage the uterine fundus, assess for a narrowing pulse pressure and mild tachycardia, and prepare to establish an additional large-bore IV line.
In the event of a postpartum hemorrhage, the immediate priority is to stop the bleeding, most commonly achieved by massaging a boggy uterus to stimulate contraction. Simultaneously, the nurse must prepare for hemodynamic instability by securing large-bore IV access for rapid fluid or blood administration. Furthermore, the nurse must actively monitor for early compensatory signs of hypovolemic shock, such as mild tachycardia and a narrowing pulse pressure, to intervene before profound hypotension occurs.

Step-by-Step Solution

1
Identify the clinical emergency based on the client's presentation.
The saturation of a perineal pad in 15 minutes combined with lightheadedness indicates active postpartum hemorrhage.
Rapid recognition of excessive blood loss is critical to prevent severe hypovolemia.
2
Prioritize immediate, safe nursing interventions to manage the bleeding and prepare for resuscitation.
Selected actions include fundal massage (to stop bleeding), recognizing early shock signs, and securing large-bore IV access.
These interventions directly address the most likely cause (uterine atony) and prepare the client for potential hemodynamic instability.
3
Eliminate unsafe or inappropriate actions.
Delegating oxygen, ambulating the client, and waiting for late shock signs are rejected.
These actions compromise patient safety, violate delegation principles, or demonstrate a failure to recognize early physiological deterioration.

Key Concept

Postpartum Hemorrhage and Hypovolemic Shock Management
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Topics

Ante/Intra/Postpartum and Newborn Care

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