QUESTION: "A primipara has delivered her baby, with labor, delivery, recovery, and the postpartum period in the same hospital room. The client had a midline episiotomy and epidural anesthesia. While assessing the client's pulse 30 minutes after the delivery, the nurse determines that the pulse rate is 60 bpm. Which of the following would the nurse do?"
CHOICES
( O ) a.) Nothing, because this pulse rate is considered a normal finding.
( X ) b.) Contact the client's physician to notify about the pulse rate.
( X ) c.) Check the client's record to determine the amount of blood loss.
( X ) d.) Recheck the pulse in 30 minutes, and compare the two readings.
RATIONALE: Bradycardia, pulse rate of 60 bpm or less, is a normal assessment finding for 6 to 10 days in the postpartum period as the woman's body adjusts to the nonpregnant state. The physician does not need to be notified because the pulse rate is within the normal parameters for the postpartum period. Checking the client's record for the amount of blood loss would be appropriate if the client's rate was elevated (for example, above 100 bpm), suggesting possible hemorrhage. Or if the client's pulse was rapid and thready, shock might be possible. Rechecking the pulse rate in 30 minutes then comparing the two readings is unnecessary. The pulse rate, because it is within normal postpartum parameters, would need to be checked according to the agency's policy for vital sign monitoring postdelivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
