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Zorluk: KolayPhysiological Adaptation

A practical nurse (PN) is caring for a client who is 24 hours postpartum. The client reports feeling slightly dizzy when sitting up. The PN notes the heart rate is 102 beats per minute, blood pressure is 98/60 mm Hg, and the perineal pad is completely saturated with bright red blood. Which action should the PN take first?

  1. Palpate the uterine fundus and notify the registered nurse (RN) immediately.Cevap
  2. B
    Inform the client that heavy, bright red bleeding is expected at this stage.
  3. C
    Document the vital signs as stable and continue with routine morning care.
  4. D
    Provide the prescribed oral pain medication for postpartum cramping.

Cevap

The priority action is to palpate the uterine fundus and notify the registered nurse (RN) immediately to address the active hemorrhage.
The client is exhibiting clear signs of postpartum hemorrhage (saturated pad, bright red blood) leading to early hypovolemic shock (dizziness, tachycardia, borderline hypotension). The immediate priority is to physically intervene by palpating and massaging the fundus to stimulate uterine contraction, while simultaneously alerting the RN for emergency medical management.

Adım Adım Çözüm

1
Analyze the client's symptoms and vital signs.
The client has dizziness, tachycardia, mild hypotension, and a saturated perineal pad.
Identifying these findings recognizes the classic presentation of postpartum hemorrhage and early hypovolemic shock.
2
Determine the most critical physiological need.
The immediate threat is excessive blood loss affecting circulation.
According to the ABCs (Airway, Breathing, Circulation) framework, active bleeding is a circulation emergency.
3
Select the nursing intervention that directly addresses the emergency.
Palpating and massaging the fundus helps the uterus contract, and notifying the RN escalates the critical situation.
Direct action to stop the bleeding and escalating to the RN are within the PN scope of practice for emergent stabilization.

Anahtar Kavram

Recognition and initial management of postpartum hemorrhage
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Konular

Physiological Adaptation

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