# A nurse is assessing a postpartum client 12 hours after vaginal delivery. Which assessment finding requires immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543092 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is assessing a postpartum client 12 hours after vaginal delivery. Which assessment finding requires immediate nursing intervention? ## 보기 1. Lochia rubra with small clots 2. Fundus firm at umbilicus level 3. Blood pressure 160/110 mmHg with headache **✔ 정답** 4. Breast engorgement with mild discomfort **정답: 3** ## 해설 Blood pressure 160/110 mmHg with headache indicates postpartum hypertension with neurological symptoms, requiring immediate intervention to prevent eclampsia or stroke. Other findings are normal postpartum assessments. ## 심화 해설 Clinical Reasoning and Priority Setting The correct answer is 3. Blood pressure 160/110 mmHg with headache. This finding requires immediate nursing intervention because it represents a hypertensive emergency indicative of postpartum preeclampsia, a leading cause of preventable maternal morbidity and mortality during the fourth trimester. Pathophysiology and Clinical Rationale Postpartum preeclampsia is a severe hypertensive disorder of pregnancy that can occur up to six weeks after delivery. The pathophysiology involves systemic endothelial dysfunction and vasospasm, which can lead to reduced cerebral perfusion and increased capillary permeability. A blood pressure of 160/110 mmHg is a severe-range value that exceeds the threshold for hypertensive emergency. The concurrent headache is a critical neurological warning sign that may reflect cerebral edema or impending eclampsia, requiring rapid blood pressure control and seizure prophylaxis to prevent cerebrovascular accidents and other end-organ damage [2]. Why the Other Options Are Not the Priority - Option 1: Lochia rubra with small clots. Lochia rubra is the normal vaginal discharge expected during the first three to four days postpartum, consisting of blood, decidual tissue, and mucus. The presence of small clots is a common and benign finding at 12 hours post-delivery, provided the fundus is firm and bleeding is not excessive. This finding reflects normal uterine involution and does not indicate a complication. - Option 2: Fundus firm at umbilicus level. A firm, midline uterine fundus located at the level of the umbilicus is an expected assessment finding at 12 hours postpartum. This indicates effective uterine contraction and is a positive sign that the uterus is involuting normally, reducing the risk of postpartum hemorrhage. This finding requires routine monitoring, not immediate intervention. - Option 4: Breast engorgement with mild discomfort. Breast engorgement is a physiological process caused by increased blood and lymphatic fluid supply as milk production transitions from colostrum to mature milk. Mild discomfort is an expected, self-limiting symptom that can be managed with non-pharmacological comfort measures such as cold compresses, frequent breastfeeding, and a supportive bra. It does not constitute a clinical emergency. The Critical "Transition Gap" in Postpartum Care This clinical scenario highlights a well-documented vulnerability in maternal care. The period following hospital discharge, often called the "transition gap," is a high-risk time when traditional management strategies may fail to protect patients from late-onset hypertensive complications [2]. A nurse’s astute assessment and recognition of severe hypertension with neurological symptoms is the most critical safety net during this period. Education on recognizing such warning signs is a key component of interventions designed to improve postpartum outcomes, as enhanced knowledge directly correlates with a patient’s ability to seek timely care [1, 3]. The immediate nursing intervention for this client is to initiate seizure precautions, notify the provider urgently, and prepare to administer antihypertensive and magnesium sulfate therapy as prescribed.References (research sources) - [2]Optimizing the Transition of Care for Postpartum Preeclampsia: A Scoping Review of Management Strategies and Missed Opportunities.Research articleChrestay NZ, Chrestay NO, Brotman M. (2026) · DOI: 10.7759/cureus.108253 ## 임상 시나리오 Clinical Practice Guide: Postpartum Hypertensive Emergency Immediate Nursing Actions - Activate rapid response or emergency protocols per facility policy. - Ensure IV access and maintain the client on seizure precautions (padded side rails, suction equipment, oxygen at bedside). - Notify the obstetric provider immediately and prepare to administer antihypertensive agents (e.g., IV labetalol, IV hydralazine) as prescribed. - Initiate continuous maternal monitoring of blood pressure, heart rate, and oxygen saturation every 5-15 minutes during the acute phase. - Assess deep tendon reflexes and check for clonus to monitor for worsening central nervous system irritability. Focused Assessment - Perform a comprehensive neurological exam: level of consciousness, visual disturbances, epigastric pain, and headache severity. - Evaluate for signs of pulmonary edema (auscultate breath sounds, monitor SpO2). - Review laboratory results: complete blood count, liver enzymes, serum creatinine, and urinalysis for proteinuria. - Assess fundal height and lochia flow to rule out concurrent postpartum hemorrhage, as hypertension can mask volume depletion. Key Patient Safety Considerations - Magnesium sulfate is often initiated for seizure prophylaxis; monitor for signs of toxicity (absent patellar reflexes, respiratory depression, decreased urine output). - Maintain strict intake and output monitoring; fluid overload can exacerbate cerebral edema. - Educate the patient and family on the importance of reporting worsening headache, vision changes, or shortness of breath even after discharge, as postpartum preeclampsia can develop up to 6 weeks post-delivery. ## 핵심 개념 - **Postpartum Preeclampsia** — A hypertensive disorder occurring up to six weeks after delivery, characterized by new-onset hypertension and often proteinuria or end-organ dysfunction. - **Lochia Rubra** — The normal vaginal discharge in the first 3-4 days postpartum, consisting of blood, decidual tissue, and mucus. - **Hypertensive Emergency** — A severe blood pressure elevation (often >160/110 mmHg) with evidence of acute end-organ damage, requiring rapid lowering of blood pressure. - **Fundal Assessment** — Palpation of the uterine fundus to evaluate uterine tone, position, and involution; a firm fundus at the umbilicus is expected 12 hours postpartum. ## 같은 주제 문제 - [A nurse is assessing a postpartum client 24 hours after vaginal delivery. 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