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Ante/Intra/Postpartum and Newborn Care

Stage 1 — Recognize cues. The nurse assesses a client on the postpartum unit 60 minutes after a vaginal birth. Review the assessment note. Highlight the findings that require immediate follow-up.

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A 28-year-old G3P3 client gave birth vaginally 60 minutes ago to a 4.1-kg infant after oxytocin-augmented labor lasting 14 hours. She had a postpartum hemorrhage after her last birth. The placenta delivered intact. At the 15-minute check, the fundus was firm at the umbilicus and midline with QBL of 300 mL and moderate lochia. Since birth she has voided a small unmeasured amount only once. Admission BP was 124/78. Now: BP 92/58 and HR 116, RR 22, T 36.9 C, and SpO2 98 percent on room air. She is pale and reports new lightheadedness. The uterus is soft and boggy, with the fundus 2 cm above the umbilicus, deviated right. There is heavy lochia with clots; QBL now 700 mL. She rates cramping 4/10 during breastfeeding, and the perineum is intact with mild edema.
A 28-year-old G3P3 client gave birth vaginally 60 minutes ago to a 4.1-kg infant after oxytocin-augmented labor lasting 14 hours. She had a postpartum hemorrhage after her last birth. The placenta delivered intact. At the 15-minute check, the fundus was firm at the umbilicus and midline with QBL of 300 mL and moderate lochia. Since birth she has voided a small unmeasured amount only once. Admission BP was 124/78. Now: BP 92/58 and HR 116, RR 22, T 36.9 C, and SpO2 98 percent on room air. She is pale and reports new lightheadedness. The uterus is soft and boggy, with the fundus 2 cm above the umbilicus, deviated right. There is heavy lochia with clots; QBL now 700 mL. She rates cramping 4/10 during breastfeeding, and the perineum is intact with mild edema.
Explanation
Compared with the firm midline fundus and QBL of 300 mL at 15 minutes, the uterus is now soft and boggy, the fundus is 2 cm above the umbilicus and deviated right, and QBL has risen to 700 mL with clots, which signals active bleeding. BP 92/58 with HR 116 is a marked fall from the admission 124/78, and a single small void since birth suggests a distended bladder that can displace the uterus and worsen atony. The earlier firm fundus, intact placenta, afterpains, and mild perineal edema are expected findings, and the risk factors in the history are unselectable background.
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