Question

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the primary health care provider (PHCP), what is the nurse's next action?

A. Administer pain medication
B. Apply ice to the vulvar area
C. Prepare the client for surgical evacuation
D. Encourage the client to ambulate

Answer 1

The nurse's next action should be to prepare the client for surgical evacuation. Administering pain medication or applying ice may provide temporary relief but will not address the underlying issue, and encouraging the client to ambulate may exacerbate the hematoma.

Step-by-step explanation:

After notifying the primary health care provider (PHCP), the nurse's next action should be to prepare the client for surgical evacuation. A vulvar hematoma is a complication that requires immediate medical attention, and surgical evacuation may be necessary to address the hematoma and prevent further complications. Administering pain medication or applying ice may provide temporary relief but will not address the underlying issue, and encouraging the client to ambulate may exacerbate the hematoma.