Maternity Nursing: Postpartum Q 10
A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:
A. Assess for hypovolemia and notify the health care provider.
B. Begin hourly pad counts and reassure the client.
C. Begin fundal massage and start oxygen by mask.
D. Elevate the head of the bed and assess vital signs.
Correct Answer: A. Assess for hypovolemia and notify the health care provider.
Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider. Patients with hypovolemic shock have severe hypovolemia with decreased peripheral perfusion. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure.
Option B: The first factor to be considered is whether the hypovolemic shock has resulted from hemorrhage or fluid losses, as this will dictate treatment. When etiology of hypovolemic shock has been determined, replacement of blood or fluid loss should be carried out as soon as possible to minimize tissue ischemia.
Option C: Medical management with uterotonic and pharmacologic agents is typically the first step if uterine atony is identified. While oxytocin is given routinely by most institutions at the time of delivery (see prevention), additional uterotonic medications may be given with bimanual massage in an initial response to hemorrhage. Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins.
Option D: Initial evaluation of the patient should include a rapid assessment of the patient’s status and risk factors. In postpartum women, signs or symptoms of blood loss such as tachycardia and hypotension may be masked, so if these signs are present, there should be a concern for considerable blood volume loss (greater than 25% of total blood volume). Continuous assessment of vital signs and on-going estimation of total blood loss is an important factor in ensuring safe care of the patient with PPH.