A nurse is assessing a woman who had a postpartum hemorrhage treated with fundal massage and oxytocin (Pitocin). Which assessment finding would require the nurse to intervene immediately?
A.
Mean arterial pressure of 58 mm Hg
B.
Pain of 4 on a pain scale of 1 (least amount) to 10 (most amount) 1 hour after the pain medication was administered
C.
Used perineal pad weight of +80 g in 2 hours
D.
Urinary bladder nondistended, no urge to void
ANS: A
One of the first signs of hypovolemic shock is a decrease in mean arterial pressure (MAP). MAP should be at least 60 mm Hg. To determine MAP, add the systolic pressure to the doubled diastolic pressure, and divide that sum by 3. The pain level may or may not be improved after medication; the nurse needs further information to determine if the medication has been effective. A perineal pad can hold 50 to 80 mL; 1 g of weight equals 1 mL of fluid, so this pad holds 80 mL. An 80-mL blood loss in 2 hours is not alarming. A distended bladder can contribute to uterine atony (and bleeding), so a nondistended bladder and no patient urge to void does not warrant intervention.
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