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Difficulty: HardAnte/Intra/Postpartum and Newborn Care

Following a precipitous vaginal birth of a macrosomic newborn, a client is transferred to the postpartum unit. During the initial assessment 45 minutes after delivery, the nurse observes a continuous, steady trickle of bright red vaginal blood. Palpation reveals the uterine fundus is midline and firmly contracted at the level of the umbilicus. The client's heart rate is 118 beats/minute, blood pressure is 90/58 mmHg, and respiratory rate is 22 breaths/minute. The client states, "I feel incredibly dizzy and my mouth is extremely dry." Which action is the highest priority for the nurse to perform?

  1. A
    Give an intramuscular injection of a uterotonic agent to stimulate further myometrial contractions.
  2. B
    Help the client stand and walk to the bathroom to void, as a distended bladder can cause hemorrhage.
  3. C
    Record the bleeding as heavy but normal lochia rubra and continue routine monitoring of vital signs.
  4. Initiate a rapid infusion of isotonic intravenous fluids and immediately notify the attending provider.Answer

Answer

Initiate a rapid infusion of isotonic intravenous fluids and immediately notify the attending provider.
The clinical presentation of a continuous trickle of bright red blood alongside a firm, midline fundus strongly suggests a genital tract laceration (trauma) rather than uterine atony (tone). The client's tachycardia, hypotension, dizziness, and extreme thirst are early physiological indicators of hypovolemic shock. Because a laceration requires surgical repair, the immediate priority is to support the client's circulating volume with intravenous fluids and notify the provider for definitive intervention.

Step-by-Step Solution

1
Analyze the physical assessment findings of the uterus.
The uterine fundus is firm and midline, indicating the uterus is well-contracted. Uterine atony and bladder distention are ruled out as primary causes of the bleeding.
Establishing the tone of the uterus is the crucial first step in differentiating the etiology of postpartum hemorrhage (the 4 Ts: Tone, Trauma, Tissue, Thrombin).
2
Interpret the characteristics of the vaginal bleeding.
A continuous, steady trickle of bright red blood in the presence of a firmly contracted uterus strongly points to trauma, such as a cervical, vaginal, or perineal laceration.
Lacerations are common following precipitous births or the delivery of a macrosomic infant, causing persistent arterial or venous bleeding despite a firm fundus.
3
Evaluate the client's vital signs and reported symptoms.
Tachycardia (118 bpm), hypotension (90/58 mmHg), dizziness, and extreme thirst indicate decreasing intravascular volume and the onset of early hemorrhagic shock.
Recognizing early shock is critical for initiating timely resuscitation before severe end-organ perfusion deficits occur.
4
Select the priority nursing intervention.
The nurse must simultaneously initiate intravenous fluid resuscitation to stabilize hemodynamics and notify the obstetric provider for surgical repair of the laceration.
Genital tract lacerations cannot be managed with standard nursing interventions like fundal massage or medications; they require definitive surgical repair by a healthcare provider.

Key Concept

Differentiation and management of postpartum hemorrhage etiologies (Atony vs. Laceration)
Estimated Time:1m 15s
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Topics

Ante/Intra/Postpartum and Newborn Care

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