A nurse is caring for a multiparous client who experienced a precipitous vaginal delivery of a macrosomic newborn 4 hours ago. The nurse asks the unlicensed assistive personnel (UAP) to obtain the client's vital signs. The UAP reports a blood pressure of 108/86 mmHg, heart rate of 114 beats/min, and respiratory rate of 20 breaths/min. The client reports feeling slightly lightheaded when attempting to sit up. Which of the following is the priority nursing action?
- Assess the client's uterine fundus and current amount of lochia.Answer
- BReassure the client that mild tachycardia and dizziness are expected fluid shift responses.
- CInstruct the UAP to assist the client to the bathroom to empty her bladder.
- DElevate the head of the bed to a high Fowler's position to relieve the lightheadedness.
Answer
The correct action is to immediately assess the client's uterine fundus and current amount of lochia.
The correct answer involves immediately assessing the client's uterine fundus and lochia. The client possesses multiple risk factors for postpartum hemorrhage, including multiparity, precipitous delivery, and uterine overdistention from a macrosomic newborn. The vital signs reveal a narrowed pulse pressure and tachycardia, accompanied by lightheadedness. These are classic early signs of hypovolemic shock secondary to blood loss. According to the nursing process, the priority is to directly assess the source of the suspected bleeding (uterine atony) to guide appropriate resuscitation and medical management.
Step-by-Step Solution
Key Concept
Postpartum Hemorrhage Risk Recognition and Priority Assessment