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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

A registered nurse is evaluating a client who is 2 hours postpartum following a forceps-assisted vaginal delivery of a macrosomic infant. The client's uterine fundus is firm, midline, and one centimeter below the umbilicus, with scant rubra lochia on the perineal pad. The client reports severe, unremitting pelvic and vaginal pain that is unrelieved by ibuprofen. The client's current heart rate is 114 beats/min and blood pressure is 102/64 mm Hg. Which of the following actions should the nurse take? (Select all that apply.)

  1. Inspect the perineal and vulvar areas for localized swelling, tenseness, or bluish discolorationAnswer
  2. B
    Delegate the continuous monitoring of the client's vital signs and pain level to the unlicensed assistive personnel (UAP)
  3. Notify the healthcare provider immediately regarding the client's severe pain and elevated heart rateAnswer
  4. D
    Reassure the client that intense perineal discomfort is an expected physiological response after a forceps-assisted delivery
  5. E
    Prioritize assisting a stable postpartum client in the adjacent room with breastfeeding before continuing this evaluation
  6. Ensure the client has patent large-bore intravenous access and prepare for potential isotonic fluid resuscitationAnswer

Answer

The correct actions include inspecting the perineum for signs of a hematoma, notifying the healthcare provider immediately, and ensuring large-bore IV access for potential fluid resuscitation.
The client's presentation of severe, unremitting perineal pain despite analgesia, combined with a firm fundus, scant lochia, and tachycardia, strongly suggests a vaginal or vulvar hematoma (a form of concealed postpartum hemorrhage). The nurse must immediately inspect the perineum to assess the extent of the hematoma, notify the healthcare provider because surgical intervention may be required, and secure large-bore IV access to prepare for fluid resuscitation to manage early hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has severe, unremitting pain out of proportion to the visible trauma, a firm fundus, scant external bleeding, and unexpected tachycardia (HR 114 beats/min).
These assessment findings are hallmark indicators of a concealed postpartum hemorrhage, most likely a vaginal or vulvar hematoma resulting from the operative delivery.
2
Determine the immediate nursing assessment priorities.
The nurse must directly inspect the perineal and vulvar areas for physical signs of a hematoma, such as localized swelling, tenseness, or bluish discoloration.
Direct visual assessment confirms the clinical suspicion of a hematoma before interventions are finalized.
3
Formulate a plan for collaborative care and emergency intervention.
The nurse must notify the provider immediately and establish or confirm large-bore IV access.
A hematoma may require surgical evacuation. The client's tachycardia indicates early hypovolemia, necessitating readiness for rapid isotonic fluid or blood product administration.

Key Concept

Recognition and Management of Postpartum Hematoma
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Topics

Ante/Intra/Postpartum and Newborn Care

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