A client has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus
The client now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to:
a. evaluate intake and output of the past 12 hours following birth.
b. initiate a rapid response intervention.
c. obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs).
d. reposition the client and reassess in 15 minutes. Initiate frequent vital sign assessments.
ANS: B
Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent client history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the client's complaints of difficulty breathing suggest that the client is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the client can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the client, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.
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