Which of the following findings would alert the nurse to initiate nursing actions to prevent postpartum complications?

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2019

Explanation

A blood pressure of 90/50 mmHg is indicative of hypotension.
In the immediate postpartum period, hypotension is a cardinal sign of postpartum hemorrhage (PPH), which can lead to hypovolemic shock.
PPH is a life-threatening emergency requiring immediate assessment and intervention to stabilize the patient and prevent further blood loss.
This finding is the most critical among the options as it signals a potentially severe and acute complication.

Option A: A temperature of 38°C (100.4°F) within the first 24 hours postpartum is considered a normal physiological response to the exertion of labor and dehydration. It is often referred to as postpartum physiological fever.
Option C: A urinary output of 60 ml/hour is a sign of adequate renal perfusion and hydration. The minimum acceptable urinary output is 30 ml/hour.
Option D: Lochia saturating a perineal pad by 6 inches is classified as moderate lochia, which is a normal and expected finding in the early postpartum period.

Clinical Relevance

Nursing practice connection: Use the key finding related to Recognition of postpartum complications and prioritization of nursing actions to guide bedside assessment, documentation, and the next nursing action.
Early recognition of postpartum hemorrhage is a critical nursing responsibility. Hypotension is a key, albeit sometimes late, sign of significant blood loss.
Nurses must perform regular postpartum assessments (BUBBLE-HE: Breasts, Uterus, Bowel, Bladder, Lochia, Episiotomy, Homan's sign, Emotional status) to detect deviations from normal.
Promptly massaging a boggy fundus, ensuring an empty bladder, and notifying the provider are life-saving interventions.

How to Approach the Question

First, read the question carefully to understand what it's asking. The keyword is 'alert the nurse,' which means you need to identify the most abnormal and potentially dangerous finding.
Next, evaluate each option against your knowledge of normal postpartum physiological changes.
Option A (Temp 38°C): Recall that a slight fever in the first 24 hours is common due to dehydration and labor.
Option B (BP 90/50 mmHg): Recognize this as hypotension. In a postpartum context, immediately link hypotension to the risk of hemorrhage (PPH).
Option C (Urine output 60 ml/hr): Know that normal urine output is >30 ml/hr, so 60 ml/hr is a healthy sign.
Option D (Lochia 6 inches): Remember the classifications of lochia amount (scant, light, moderate, heavy). Six inches is moderate and normal.

Concept Tested & Keywords

Concept Tested: Recognition of postpartum complications and prioritization of nursing actions.
Stem keywords: postpartum complications, nursing actions, alert the nurse
Lead-in keywords: Which
Clinical cues: Blood pressure of 90/50 mmHg 2 hours after delivery, which is a sign of hypotension.

QOcjThbn1MO0ZY2T7wPxsN

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 1-3

Practise the full RUHS, Jaipur, PB B.Sc Nursing Entrance-2019

Attempt every question from this paper in a timed mock, then review the full solution for each one.