Question

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

1) Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg
2) Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg
3) Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg
4) Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg

Answer 1

The nurse should be most concerned with vital signs indicating tachycardia and hypotension (option 1), as these are signs of postpartum hemorrhage or shock, especially given the woman's significant estimated blood loss.

Step-by-step explanation:

When evaluating the woman's vital signs postpartum, particularly after a significant estimated blood loss (EBL) of 1500 ml, the greatest concern for the nurse would be option 1: Temperature 37.9° C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg. This set of vital signs indicates tachycardia (increased heart rate) and hypotension (low blood pressure), which are signs of postpartum hemorrhage or shock, inciting imminent concern.

Postpartum haemorrhage is a medical emergency that requires immediate intervention to prevent further blood loss and stabilize the patient. A normal heart rate for a resting adult is between 60 to 100 bpm, and normal blood pressure is generally considered within the range of 90/60 mm Hg to 120/80 mm Hg. Therefore, the signs displayed in option 1 are most critical and need to be addressed quickly to ensure the well-being of the postpartum woman.