A nurse is assessing a woman who had a postpartum hemorrhage ...

[K@]

A nurse is assessing a woman who had a postpartum hemorrhage treated with fundal massage and oxytocin (Pitocin). Which assessment finding would require the nurse to intervene immediately?
 
  A.
  Mean arterial pressure of 58 mm Hg
  B.
  Pain of 4 on a pain scale of 1 (least amount) to 10 (most amount) 1 hour after the pain medication was administered
  C.
  Used perineal pad weight of +80 g in 2 hours
  D.
  Urinary bladder nondistended, no urge to void

Question 2

A nurse is assessing a patient for a perineal hematoma. Which action by the nurse is most appropriate?
 
  A.
  Assist the woman to a knee-chest position with head down.
  B.
  Have the patient lie supine and place her legs in frog-leg position.
  C.
  Place the patient in a side-lying position and lift the upper buttock.
  D.
  Turn the woman side to side and lift the upper leg each time.

[tdewitt]

Answer to Question 1

ANS: A
One of the first signs of hypovolemic shock is a decrease in mean arterial pressure (MAP). MAP should be at least 60 mm Hg. To determine MAP, add the systolic pressure to the doubled diastolic pressure, and divide that sum by 3. The pain level may or may not be improved after medication; the nurse needs further information to determine if the medication has been effective. A perineal pad can hold 50 to 80 mL; 1 g of weight equals 1 mL of fluid, so this pad holds 80 mL. An 80-mL blood loss in 2 hours is not alarming. A distended bladder can contribute to uterine atony (and bleeding), so a nondistended bladder and no patient urge to void does not warrant intervention.

Answer to Question 2

ANS: C
To correctly assess for a perineal hematoma, assist the woman to a side-lying position and gently lift the upper buttock. Ask the patient to bear down and assess for full or bulging tissue, blue discoloration of tissue, and tenderness.

[K@]

Excellent

[alvinum]

Gracias!