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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

The nurse receives the shift handoff report for four postpartum clients on the maternal-newborn unit. Which client should the nurse assess first?

  1. A client 6 hours following a forceps-assisted vaginal delivery who reports severe, unrelenting vaginal pressure and rectal pain that is not relieved by prescribed analgesics.Answer
  2. B
    A client 2 hours post-spontaneous vaginal delivery who saturated one perineal pad over the last 90 minutes and has a firm fundus located at the umbilicus.
  3. C
    A client 12 hours post-cesarean delivery who reports transient dizziness and lightheadedness when transitioning from a supine to a seated position.
  4. D
    A client 24 hours post-delivery who exhibits a sudden onset of shivering and a low-grade temperature of 100.1°F (37.8°C).

Answer

The client 6 hours following a forceps-assisted vaginal delivery who reports severe, unrelenting vaginal pressure and rectal pain.
Severe, unrelenting vaginal or rectal pressure, especially following an operative vaginal delivery (such as a forceps or vacuum extraction), is a cardinal sign of a developing vaginal or vulvar hematoma. Hematomas involve concealed bleeding into the soft tissues, which can lead to significant blood loss and hypovolemic shock if left untreated. The pain associated with a hematoma is typically disproportionate to the expected postpartum discomfort and is not relieved by standard analgesics. Because this condition represents an acute, unstable, and potentially life-threatening complication, this client requires immediate assessment and intervention.

Step-by-Step Solution

1
Analyze the clinical presentation of each client to differentiate expected postpartum physiological adaptations from potential life-threatening complications.
Identified that clients with moderate lochia, orthostatic hypotension, and a mild temperature elevation are experiencing normal, expected postpartum adaptations.
Prioritization requires identifying the client at the highest risk for physiological instability.
2
Evaluate the clinical significance of severe, unrelenting vaginal and rectal pressure.
Recognized this symptom, especially following an operative vaginal delivery, as a hallmark sign of a pelvic hematoma.
A pelvic hematoma causes concealed bleeding into the tissues, which can rapidly lead to hypovolemic shock if unrecognized.
3
Apply prioritization principles to select the client requiring immediate intervention.
Selected the client with the suspected hematoma as the highest priority.
Concealed hemorrhage poses an immediate threat to the client's hemodynamic stability and requires urgent surgical or medical evaluation.

Key Concept

Prioritization of Postpartum Complications: Recognition of Pelvic Hematoma
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Topics

Ante/Intra/Postpartum and Newborn Care

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