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Question

Difficulty: HardEstablishing Priorities

Following the shift handoff report on a maternal-newborn unit, the registered nurse prepares to evaluate four assigned clients. Which client requires the nurse's immediate assessment?

  1. A
    A client 4 hours post-vaginal delivery who expelled a small clot during fundal massage, resulting in a firm, midline uterus
  2. B
    A client 18 hours post-cesarean delivery exhibiting shallow respirations, diminished basilar breath sounds, and an oxygen saturation of 94% on room air
  3. A client 2 hours post-cesarean delivery who reports new-onset right shoulder pain and demonstrates a narrowing pulse pressureAnswer
  4. D
    A client 24 hours postpartum with gestational hypertension who reports a mild generalized headache and exhibits 2+ patellar reflexes

Answer

The client 2 hours post-cesarean delivery who reports new-onset right shoulder pain and demonstrates a narrowing pulse pressure.
This client is exhibiting signs of concealed internal hemorrhage, an acute and life-threatening complication. New-onset right shoulder pain (Kehr's sign) occurs when blood collects in the peritoneal cavity and irritates the phrenic nerve. Additionally, a narrowing pulse pressure is a critical, early compensatory sign of hypovolemic shock as peripheral vasoconstriction attempts to maintain blood pressure. This represents an unstable condition requiring immediate emergency intervention.

Step-by-Step Solution

1
Analyze the clinical presentation of the post-cesarean client.
Identified the presence of new-onset right shoulder pain and a narrowing pulse pressure.
To recognize subtle but critical physiological cues of clinical deterioration.
2
Correlate the assessment findings with potential pathophysiological complications.
Determined that the shoulder pain indicates Kehr's sign (phrenic nerve irritation from internal bleeding) and the narrowing pulse pressure indicates compensatory hypovolemic shock.
To evaluate the severity and underlying cause of the symptoms.
3
Compare the acuity of all four clients using prioritization frameworks (acute vs. chronic, unexpected vs. expected).
Concluded that the post-cesarean client has unexpected, acute, life-threatening symptoms, while the other clients have expected or stable physiological findings.
To identify the highest priority client requiring immediate emergency intervention.

Key Concept

Prioritization of care based on recognizing early, subtle indicators of internal hemorrhage and hypovolemic shock.
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Establishing Priorities

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