A practical nurse (PN) is caring for a client who had an uncomplicated vaginal delivery 4 hours ago. The client reports feeling dizzy. The PN observes that the client's perineal pad, which was changed 30 minutes ago, is now completely saturated with dark red blood. Current vital signs are blood pressure 96/58 mm Hg and heart rate 115 beats/min. Which of the following actions should the PN take first?
- Massage the client's uterine fundus and immediately alert the registered nurse (RN).Cevap
- BDocument the pad saturation as an expected lochia rubra pattern.
- CReassure the client that dizziness is common and recheck the vital signs in one hour.
- DAssist the client to the bathroom so she can empty her bladder.
Cevap
Massage the client's uterine fundus and immediately alert the registered nurse (RN).
The client is displaying explicit signs of postpartum hemorrhage (saturating a pad in less than 1 hour) and early hypovolemic shock (dizziness, tachycardia, and hypotension). The priority action within the practical nurse's scope is to palpate and massage the uterine fundus to stimulate contraction and control the bleeding, while simultaneously notifying the registered nurse (RN) for immediate collaborative intervention.
Adım Adım Çözüm
Anahtar Kavram
Recognizing and Managing Postpartum Hemorrhage and Hypovolemic Shock