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Case Scenario: The Unfolding Situation Client Profile: Name: Elena Rodriguez, 28 years old (G3P3) Current Status: 2 hours postpartum following a spontaneous vaginal delivery Infant Weight: 9 lbs 4 oz (4200g) History: Prolonged second stage of labor (3 hours); history of large infants Initial Postpartum Assessment (0800): The nurse performs the first assessment since transfer from labor and delivery. Elena is breastfeeding her newborn. Fundus: 1 cm above the umbilicus, midline, and firm Lochia: Rubra, moderate amount; no clots noted Vital Signs: BP 118/76, HR 82, RR 16, 98% on room air The Complication Begins (0930) Elena calls the nurse, stating, "I feel like I'm sitting in a puddle, and I'm starting to feel very dizzy and lightheaded". Current Assessment Findings: Fundus: Displaced to the right, 3 cm above the umbilicus, and feels soft/boggy upon palpation Lochia: Large amount of rubra lochia; peripad and underpad are saturated with several large clots (approx. 5 cm) Vital Signs: BP 92/54, HR 115, RR 24, 94% on room air
1. Recognizing Cues (Select All That Apply) Which findings from the 0930 assessment require immediate intervention? A. Fundus displaced to the right B. Heart rate of 115 bpm C. Saturated peripad and underpad D. Breastfeeding status E. Patient reporting dizziness F. Respiratory rate of 24
2. Analyzing Cues (Prioritization) The nurse identifies that the client is at highest risk for which complication? A. Septic Shock B. Hypovolemic Shock C. Pulmonary Embolism D. Disseminated Intravascular Coagulation (DIC) 3. Generating Solutions (Prioritized Nursing Actions) What is the nurse’s first priority action for this client? A. Administer oxygen via non-rebreather mask B. Notify the healthcare provider C. Perform fundal massage until firm D. Increase the IV fluid rate Medical Orders Received (0935) The provider arrives and issues the following stat orders: 1. Fundal massage continuous until firm. 2. Catheterize the patient immediately. 3. Oxytocin (Pitocin) 20 units in 1,000 mL Lactated Ringer’s at 200 mL/hr. 4. Methylergonovine (Methergine) 0.2 mg IM now. 5. Type and Crossmatch for 2 units of Packed Red Blood Cells (PRBCs). **NGN Style Questions (Continued)
- Taking Action: Priority Interventions** The nurse notes the fundus is displaced to the right and 3 cm above the umbilicus. Which action should the nurse perform first? A. Start the Oxytocin infusion. B. Administer the Methylergonovine IM. C. Assist the patient to the bathroom to void. D. Insert the straight catheter as ordered. 5. Analyzing Cues: Contraindications Before administering Methylergonovine (Methergine) , which finding in the patient's chart would cause the nurse to withhold the medication and notify the provider? Current Vital Signs: BP 152/94, HR 110, RR 22. Medical History: Asthma and seasonal allergies. Lab Results: Hemoglobin 9.2 g/dL.
Final Phase: Evaluating Quantitative Blood Loss (QBL) The Scenario: The hemorrhage is now controlled. To determine if Elena needs a blood transfusion, the nurse must calculate the QBL by weighing the blood-soaked materials used during the emergency. Data Collected: Dry weight of one peripad: 20 grams Dry weight of one underpad (chux): 50 grams Wet weight of 2 saturated peripads: 340 grams total Wet weight of 1 saturated underpad: 850 grams Conversion Factor:
8. Calculation: Evaluation of Blood Loss Calculate the total Quantitative Blood Loss (QBL) in mL. (Enter numerical value only). Answer: ________ mL 9. Evaluation: Clinical Significance Based on the calculation above and the definition of Postpartum Hemorrhage, how should the nurse document and report this finding? A. This is a normal amount of blood loss for a G3P3 patient. B. This is a Stage 1 Hemorrhage (>500ml for vaginal birth). C. This is a Stage 2 Hemorrhage (>1000mlffor vaginal birth). D. This is a minor bleed; no further monitoring is required. Please also complete a concept map for this patient with one diagnosis, rationales, goals, interventions and evaluations of goals. Use the medsurg diagnosis format and add the pertinent labs, data, etc.
1. Recognizing Cues (Select All That Apply) Findings requiring immediate intervention at 0930: ✅ A. Fundus displaced to the right ✅ B. Heart rate of 115 bpm ✅ C. Saturated peripad and underpad ✅ E. Patient reporting dizziness ✅ F. Respiratory rate of 24 ✅ D. Breastfeeding status Rationale A boggy, displaced fundus indicates uterine atony , the leading cause of PPH. Tachycardia, hypotension, dizziness, and tachypnea are early signs of hypovolemia. Heavy lochia with large clots signals active hemorrhage.
Breastfeeding is not an acute abnormal cue.
2. Analyzing Cues: Prioritization Highest-risk complication: ✅ B. Hypovolemic Shock Rationale Blood loss from uterine atony results in decreased circulating volume, causing hypotension, tachycardia, and decreased tissue perfusion. 3. Generating Solutions: First Priority Action ✅ C. Perform fundal massage until firm Rationale
7. Medication Matrix Medication Statement Correct Column Oxytocin (Pitocin) Monitor for water intoxication and hyponatremia ✅ Nursing Consideration Methylergonovine (Methergine) Do not administer if history of hypertension ✅ Contraindication Carboprost (Hemabate) Avoid use in asthma ✅ Contraindication Carboprost (Hemabate) Administer anti-diarrheal PRN ✅ Nursing Consideration Misoprostol (Cytotec) Often administered rectally ✅ Nursing Consideration Misoprostol (Cytotec) Monitor for shivering/fever ✅ Nursing **Consideration
- Quantitative Blood Loss (QBL) Calculation Step-by-step: Peripads** Wet weight: 340 g Dry weight: 2 × 20 g = 40 g Blood weight = 300 g Underpad Wet weight: 850 g Dry weight: 50 g Blood weight = 800 g Total Blood Loss 300 g + 800 g = 1100 g ≈ 1100 mL ✅ Answer: 1100 mL
9. Evaluation: Clinical Significance ✅ C. This is a Stage 2 Hemorrhage (>1000 mL for vaginal birth) Rationale Normal vaginal blood loss < 500 mL ≥1000 mL with symptoms = Stage 2 PPH → requires aggressive intervention and possible transfusion CONCEPT MAP – POSTPARTUM HEMORRHAGE Patient Summary G3P3 , 2 hours postpartum Infant: 4200 g (macrosomia) Prolonged second stage Boggy, displaced fundus Heavy lochia, hypotension, tachycardia NANDA-I Nursing Diagnosis Deficient Fluid Volume Related to: uterine atony and excessive postpartum blood loss As evidenced by: hypotension (92/54), tachycardia (HR 115), dizziness, saturated pads, large clots Pertinent Data Fundus: boggy, deviated right, +3 cm Lochia: heavy rubra with clots VS: BP ↓, HR ↑, RR ↑ QBL: 1100 mL
Evaluation of Goals ✅ Fundus firm and midline ✅ Lochia reduced ✅ Vital signs stabilized ✅ QBL documented accurately ✅ Hemorrhage controlled without further escalation
