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Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

A client who experienced a spontaneous vaginal birth of a large-for-gestational-age infant 3 hours ago reports feeling a "sudden gush of fluid" while resting in bed. The practical nurse enters the room and observes a completely saturated perineal pad, along with a continuous trickle of dark red blood pooling on the disposable underpad. The client's resting heart rate is 104 beats/min. Which action should the nurse take first?

  1. Palpate the uterine fundus to assess for firmness and position.Cevap
  2. B
    Record the lochia amount as heavy in the electronic health record.
  3. C
    Help the client ambulate to the restroom to empty her bladder.
  4. D
    Direct the assistive personnel to obtain a full set of vital signs.

Cevap

The nurse should first palpate the uterine fundus to assess for firmness and position.
The first step in addressing excessive postpartum bleeding is to immediately assess the source, which is most commonly uterine atony. By palpating the fundus, the nurse can quickly evaluate uterine tone and begin fundal massage if the uterus is boggy. This is a critical independent intervention to control hemorrhage and protect the client's circulation.

Adım Adım Çözüm

1
Analyze the clinical data presented in the scenario.
The client has a saturated pad, pooling blood, and tachycardia 3 hours after delivering a large infant.
Identifying these risk factors and signs points directly to an active postpartum hemorrhage.
2
Determine the most critical priority based on the ABCs (Airway, Breathing, Circulation).
The client is experiencing a circulation issue due to excessive blood loss.
Hemorrhage compromises circulation, requiring immediate assessment of the bleeding source.
3
Identify the appropriate initial nursing intervention within the practical nurse's scope.
Palpating the fundus is the first step.
Uterine atony is the leading cause of early postpartum hemorrhage; evaluating fundal tone determines if immediate massage is needed to contract the uterus.

Anahtar Kavram

Prioritization in Postpartum Hemorrhage Management
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Konular

Ante/Intra/Postpartum and Newborn Care

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