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Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

During morning rounds on the maternity unit, a client who delivered a healthy neonate at 39 weeks gestation is evaluated at 20 hours postpartum. The nurse reviews the client and newborn's current findings. Which observation requires immediate reporting to the registered nurse?

  1. A
    Maternal lochia rubra that saturates approximately one-third of a perineal pad in 2 hours
  2. B
    Maternal laboratory results showing a white blood cell count of 18,000/mm³
  3. Maternal resting heart rate of 114 beats per minute and a blood pressure of 88/54 mm HgCevap
  4. D
    Newborn respiratory pattern featuring irregular breathing with 10-second pauses

Cevap

The maternal resting heart rate of 114 beats per minute and a blood pressure of 88/54 mm Hg.
The combination of tachycardia and hypotension in the postpartum period is a critical early sign of hypovolemic shock, most often related to excessive blood loss. The practical nurse must immediately report these findings to the registered nurse for prompt intervention and stabilization.

Adım Adım Çözüm

1
Analyze the maternal vital signs.
Tachycardia (114 bpm) and hypotension (88/54 mm Hg) are identified.
These are subtle but critical clinical indicators of potential hemodynamic instability or hypovolemic shock.
2
Evaluate the lochia and laboratory values.
The lochia volume and elevated white blood cell count are within expected postpartum limits.
Understanding normal physiological adaptations to labor and birth prevents unnecessary escalation.
3
Assess the newborn's respiratory pattern.
Brief apneic periods of 10 seconds are observed.
This is a normal respiratory pattern (periodic breathing) for a healthy term neonate and does not indicate distress.
4
Determine the priority for reporting based on the PN scope of practice.
The unstable maternal vital signs are prioritized.
Hemodynamic compromise requires immediate RN assessment and collaborative medical intervention.

Anahtar Kavram

Prioritization of Postpartum Complications
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Konular

Ante/Intra/Postpartum and Newborn Care

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