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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

Following a spontaneous vaginal delivery complicated by a retained placenta requiring manual extraction, a client is transferred to the postpartum unit. Several hours into the shift, the unlicensed assistive personnel (UAP) records the client's vital signs: temperature 98.8°F (37.1°C), blood pressure 112/74 mm Hg, heart rate 116 beats per minute, and respirations 18 per minute. The UAP informs the registered nurse that the client appears to be resting quietly with her eyes closed. Which intervention is the most appropriate next step for the registered nurse?

  1. Proceed to the bedside to directly palpate the uterine fundus and quantify perineal bleeding.Answer
  2. B
    Instruct the UAP to encourage oral fluid intake and reassess the heart rate in 15 to 30 minutes.
  3. C
    Record the findings in the electronic health record, recognizing the tachycardia as a normal response to labor exertion.
  4. D
    Prioritize an immediate assessment of the bilateral lower extremities to rule out deep vein thrombosis.

Answer

The registered nurse must proceed to the bedside to directly palpate the uterine fundus and quantify perineal bleeding.
In the postpartum period, especially with a history of placental complications, an elevated heart rate is often the very first physiological indicator of concealed or active hemorrhage. The body compensates for blood loss by increasing the heart rate to maintain cardiac output, which keeps the blood pressure normal in the early stages of shock. The fact that the client is resting quietly does not rule out hypovolemia; therefore, direct and immediate RN assessment of the primary source of potential bleeding (the uterus and lochia) is mandatory.

Step-by-Step Solution

1
Analyze the client's clinical history for risk factors.
The client experienced a retained placenta requiring manual extraction, placing her at high risk for uterine atony and subsequent postpartum hemorrhage.
Identifying risk factors guides the nurse's index of suspicion for specific complications.
2
Evaluate the reported vital signs against normal postpartum parameters.
The blood pressure and respiratory rate are within normal limits, but the heart rate of 116 beats per minute indicates significant tachycardia.
Recognizing deviations from baseline is critical for early detection of clinical deterioration.
3
Correlate the abnormal vital sign with potential physiological complications.
Tachycardia is a primary compensatory mechanism for hypovolemia. It typically presents before hypotension, which is a late and more dangerous sign of shock.
Understanding the pathophysiology of shock prevents the nurse from being falsely reassured by a normal blood pressure or a resting client.
4
Determine the safest, highest-priority nursing intervention.
The registered nurse must immediately assess the client's circulation by checking the fundus and lochia rather than delegating, delaying, or assessing lower-priority systems.
Direct RN assessment ensures immediate intervention if a life-threatening hemorrhage is occurring.

Key Concept

Early recognition of hypovolemic shock in postpartum clients.
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Topics

Ante/Intra/Postpartum and Newborn Care

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