Exhibits

Select from the options to complete the sentence.

After listening to the client's symptoms, the nurse realizes that she likely has

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related to

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Rationale

A. JVD is typically an indicator of increased central venous pressure and can be associated with heart failure or fluid overload. In this scenario, flat JVD suggests decreased venous return, which may exacerbate the client's hypotension. While important, it may not be the most immediate concern compared to other options.

B. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, are critical signs that indicate poor cerebral perfusion. In this case, the rapid ventricular rate and possibly inadequate cardiac output may not be meeting cerebral perfusion needs, leading to altered mental status. This finding requires urgent attention to prevent further deterioration.

C. Nausea and vomiting can indicate inadequate perfusion to the gastrointestinal tract due to hypotension or impaired cardiac output. While important to assess for fluid and electrolyte balance, it is less urgent compared to potential changes in mental status or perfusion to vital organs.

D. A sudden onset headache can be indicative of various issues, including hypertension, cerebral ischemia, or intracranial hemorrhage. However, in the context of atrial fibrillation with rapid ventricular response and hypotension, other neurological signs such as altered mental status or focal neurological deficits would typically be more concerning.

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B. Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C. Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D. Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E. Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F. Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G. Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H. Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I. Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.