Examkin

Soru

Zorluk: Çok zorData Collection Techniques

A nurse working in a maternal-newborn unit is caring for a client who is 4 hours postpartum following a forceps-assisted vaginal delivery of a 4.2 kg (9 lb 4 oz) neonate. The client reports intense thirst and feeling like their heart is "fluttering," which they attribute to being awake for the past 36 hours. Vital signs show a heart rate of 118 beats/minute, blood pressure of 108/74 mm Hg, and a respiratory rate of 20 breaths/minute. The uterine fundus is firm, midline, and located at the umbilicus. A perineal pad placed 90 minutes ago exhibits a 5 cm (2 inch) stain of lochia rubra. Based on this data, which focused data collection action should the nurse perform next?

  1. Examine the perineum visually for asymmetrical swelling, bluish discoloration, or a localized mass.Cevap
  2. B
    Document the findings as expected physiological exhaustion and assist the client with oral hydration.
  3. C
    Perform an internal pelvic examination to determine if there is an actively bleeding cervical laceration.
  4. D
    Massage the uterine fundus vigorously to expel retained blood clots that may be causing the tachycardia.

Cevap

The nurse should examine the perineum visually for asymmetrical swelling, bluish discoloration, or a localized mass to check for a concealed hemorrhage.
The correct action directly addresses the clinical mismatch between the client's early signs of shock (tachycardia, intense thirst) and the lack of visible, heavy external bleeding. Because the uterus is firm and lochia is moderate/light, the nurse must suspect a concealed hemorrhage, such as a perineal hematoma. This complication is highly likely given the macrosomic infant and forceps use. Visual inspection of the perineum is a critical, in-scope data collection method to confirm this suspicion before immediately notifying the RN or provider.

Adım Adım Çözüm

1
Analyze the client's vital signs and reported symptoms.
The client has unexplained resting tachycardia (118 beats/min) and extreme thirst.
These are classic early compensatory signs of hypovolemia and potential shock, which cannot simply be dismissed as fatigue.
2
Evaluate the current physical data regarding common postpartum bleeding sources.
The fundus is firm and midline, and the lochia on the pad is minimal for a 90-minute timeframe.
This rules out uterine atony as the source of bleeding, meaning the blood loss must be concealed.
3
Correlate findings with the client's risk factors.
The client had a forceps-assisted delivery of a macrosomic (4.2 kg) infant.
These factors significantly increase the risk for trauma to the pelvic floor, specifically perineal and vaginal hematomas.
4
Select the appropriate data collection technique within the PN scope of practice.
Visually inspecting the external perineum for a hematoma (swelling, bluish mass).
Visual inspection is a foundational data collection technique within the PN scope, whereas internal pelvic exams are not.

Anahtar Kavram

Prioritizing Data Collection for Concealed Postpartum Hemorrhage
Bu soruyu puanla

Konular

Data Collection Techniques

Bu konudan daha fazla soru