# A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. Which assessment findings would alert the nurse to early postoperative hemorrhage and hypovolemia? Select all that apply.

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> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. Which assessment findings would alert the nurse to early postoperative hemorrhage and hypovolemia? Select all that apply.

1

New restlessness, anxiety, or subtle confusion noted on neurologic checks

2

Hourly urine output that has fallen from 50 mL to 20 mL over the last 2 hours

3

Warm, flushed skin and bounding peripheral pulses

4

Oxygen saturation rising above the postoperative baseline of 96 percent on room air

5

Bradycardia from increased vagal tone in response to active blood loss

6

New tachycardia with heart rate 118/min and a narrowing pulse pressure compared with baseline

## Explanation

Early hemorrhagic shock activates the sympathetic nervous system, producing tachycardia and a narrowing pulse pressure as the body compensates (Choice 6). Decreased cerebral perfusion can present as restlessness, anxiety, or new confusion before hypotension develops (Choice 1). Decreased renal perfusion appears as oliguria—less than 30 mL/hr in an adult—making the fall in urine output an important early cue (Choice 2). Bleeding causes tachycardia rather than bradycardia (Choice 5). Skin is more likely to become cool, pale, and clammy with weak pulses than warm and flushed with bounding pulses (Choice 3). A rising oxygen saturation above baseline does not indicate hemorrhage or hypovolemia (Choice 4).

## In-depth explanation

Early Hemorrhage = Compensated Shock
SNS activation → ↑HR · narrowed pulse pressure · cool skin · oliguria · restlessness. Blood pressure stays normal until ~30% volume loss.

Sentinel Sign
New restlessness or anxiety = decreased cerebral perfusion until proven otherwise. Often the first sign before vitals shift.

Memory Tip
"RAP": Restlessness, Anoxia signs, Pulse changes — early shock triad.

Caution
Do not wait for hypotension. By the time SBP drops, the client has already lost 30-40% of blood volume. Notify provider on early signs.

## Clinical scenario

Scenario
Adult, 4 hours post open abdominal hysterectomy. Baseline VS: BP 124/76, HR 78, RR 16, SpO2 96% RA. Q15min checks ongoing. Dressing dry, JP drain output increasing.

Current Findings
- HR 118, BP 116/96 (PP 20)
- Restless, asking the same questions repeatedly
- UOP 20 mL last hour (was 50 mL prior)
- Skin cool, peripheral pulses weak

Priority Action
1. Notify provider STAT — suspected post-op hemorrhage
2. Apply pressure to incision, assess drain output
3. Type & screen, CBC, coagulation panel
4. Prepare for IV fluid bolus and possible OR return

## Key concepts

- **Compensated hemorrhagic shock** — Class I-II hemorrhage (up to 30% volume loss). SNS activation maintains blood pressure with tachycardia, narrowed pulse pressure, cool skin, oliguria, anxiety. By the time blood pressure falls, decompensation has begun.
- **Pulse pressure** — Difference between systolic and diastolic BP. Normal 30-40 mmHg. Narrowing pulse pressure (less than 30) suggests early hypovolemia or cardiac tamponade. Widening (>40) suggests aortic insufficiency or increased intracranial pressure.
- **Oliguria as a perfusion marker** — Adult urine output under 30 mL/hr (or under 0.5 mL/kg/hr) indicates inadequate renal perfusion. Hourly urine output is one of the most sensitive early markers of compensated shock and hypovolemia.

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