Complications of Cesarean delivery
Complications of Cesarean delivery ( 5 Questions)
A nurse is assessing a client who had a cesarean delivery 12 hours ago.
The nurse observes that the client has soaked two perineal pads in one hour, has a heart rate of 120 beats per minute, and has a blood pressure of 90/60 mmHg.
What is the priority intervention for this client?
Apply pressure to the bleeding site. This is because the client is showing signs of postpartum hemorrhage (PPH), which is severe vaginal bleeding after childbirth. PPH can occur up to 12 weeks postpartum, but it is more common within the first 24 hours. PPH can be caused by uterine atony, retained placenta, or trauma to the reproductive organs.
Applying pressure to the bleeding site can help to control the blood loss and prevent shock.
Encourage early ambulation is wrong because it can worsen the bleeding and increase the risk of fainting. Early ambulation is beneficial for preventing thromboembolism and promoting recovery, but it should be done after the bleeding is stabilized.
Apply sterile dressings to the incision is wrong because it does not address the source of bleeding, which is likely from the vagina or uterus. The incision site may also bleed, but it is usually less than the vaginal bleeding.
Applying sterile dressings to the incision can help to prevent infection, but it is not a priority intervention for PPH.
Encourage frequent voiding is wrong because it can cause bladder distension and interfere with uterine contraction. A full bladder can displace the uterus and prevent it from compressing the blood vessels where the placenta was attached.
Encouraging frequent voiding can help to maintain bladder function and reduce discomfort, but it is not a priority intervention for PPH.
Normal ranges for heart rate are 60-100 beats per minute and for blood pressure are 90/60-120/80 mmHg. Normal blood loss after cesarean delivery is less than 1000 mL.
The correct answer is choice A. Apply pressure to the bleeding site. This is because the client is showing signs of postpartum hemorrhage (PPH), which is severe vaginal bleeding after childbirth. PPH can occur up to 12 weeks postpartum, but it is more common within the first 24 hours. PPH can be caused by uterine atony, retained placenta, or trauma to the reproductive organs.
Applying pressure to the bleeding site can help to control the blood loss and prevent shock.
Choice B. Encourage early ambulation is wrong because it can worsen the bleeding and increase the risk of fainting. Early ambulation is beneficial for preventing thromboembolism and promoting recovery, but it should be done after the bleeding is stabilized.
Choice C. Apply sterile dressings to the incision is wrong because it does not address the source of bleeding, which is likely from the vagina or uterus. The incision site may also bleed, but it is usually less than the vaginal bleeding.
Applying sterile dressings to the incision can help to prevent infection, but it is not a priority intervention for PPH.
Choice D. Encourage frequent voiding is wrong because it can cause bladder distension and interfere with uterine contraction. A full bladder can displace the uterus and prevent it from compressing the blood vessels where the placenta was attached.
Encouraging frequent voiding can help to maintain bladder function and reduce discomfort, but it is not a priority intervention for PPH.
Normal ranges for heart rate are 60-100 beats per minute and for blood pressure are 90/60-120/80 mmHg. Normal blood loss after cesarean delivery is less than 1000 mL.