QUESTION: "Which of the following would the nurse use to assess a client for possible uterine atony after a cesarean delivery? "
CHOICES
( X ) a.) Check the abdominal dressing every 15 minutes for the first hour.
( O ) b.) Palpate the fundus every 15 minutes for at least 1 hour.
( X ) c.) Observe the amount of lochia immediately after delivery.
( X ) d.) Assess blood pressure and pulse every 15 minutes for 1 hour.
RATIONALE: Uterine atony, relaxation of the uterus, can result in postpartum hemorrhage and possible death. Every postpartum client, regardless of the type of delivery, is at risk for uterine atony and hemorrhage. Even though an abdominal incision and abdominal dressing are present, the nurse should palpate the fundus gently while supporting the incision every 15 minutes for at least 1 hour, more frequently if vaginal bleeding is moderate or severe and if the fundus is soft or boggy. Although the nurse also should observe and note any bleeding on the abdominal incision dressings, this is not an accurate measure of uterine atony. The nurse should note the amount of lochia immediately after delivery and during the recovery period, usually about 2 hours. However, this is not an accurate measure of uterine atony because bleeding, which may be internal, may be concealed. Uterine atony is best detected by palpation of the fundus. Hypotension and tachycardia may be late signs of hypovolemic shock due to hemorrhage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
